See the table below for a summary of medication policy additions and changes that require provider notification, including pre-authorization requirements. Note: Policies are available online on the effective date of the addition or change.
Pre-authorization: Submit medication pre-authorization requests through CoverMyMeds.
Expert feedback: We routinely assess our medication policies based on updated medical literature, national treatment guidelines, practicing provider feedback and pharmaceutical market changes. If you’d like to provide feedback or be added to our distribution list, please email our Medication Policy team and indicate your specialty.
New FDA-approved medications: New-to-market medications are subject to pre-authorization based on their FDA-labeled indication, pivot trial criteria and dosage limitations until we complete a full medication review and develop a coverage policy.
Product not available (PNA) status: We allow a 90-day grace period to use any existing supply for medications that CMS has designated as PNA before they become ineligible for reimbursement. See our Non-Reimbursable Services (Administrative #107) reimbursement policy.
Effective date | Policy name | Policy number | Description | New or revised | Notification date |
|---|---|---|---|---|---|
May 1, 2025 | Trodelvy, sacituzumab govitecan-hziy | Dru645 | The use of Trodelvy (sacituzumab govitecan-hziy) for previously treated advanced urothelial carcinoma is considered investigational as the FDA recently withdrew this indication | Revised | June 1, 2025 |
July 1, 2025 | Camzyos, mavacamten | Dru720 | The concomitant use of Camzyos with disopyramide is considered investigational and therefore not covered | Revised | April 1, 2025 |
July 1, 2025 | CGRP Monoclonal Antibodies | Dru540 | The concomitant use of multiple CGRP agents (oral or injectable) is considered investigational and therefore not covered | Revised | April 1, 2025 |
July 1, 2025 | Hemlibra, emicizumab-kxwh | Dru539 | The concomitant use of Hemlibra with other non-factor hemophilia prophylactic products is considered investigational and therefore not covered | Revised | April 1, 2025 |
July 1, 2025 | Medications for transthyretin-mediated amyloidosis | Dru733 |
| Revised | April 1, 2025 |
July 1, 2025 | Provider-Administered Specialty Drugs | Dru764 | Added the following products to the Provider-Administered Specialty Drug List:
| Revised | April 1, 2025 |
July 1, 2025 | Saphnelo, anifrolumab | Dru688 | Adding step therapy requirement for new utilizers through Benlysta (belimumab) in addition to conventional oral therapies | Revised | April 17, 2025 |
July 1, 2025 | Self-administered CGRP antagonists and 5-HT 1f agonists | Dru635 | The concomitant use of prophylactic agents (oral or injectable) is considered investigational and therefore not covered | Revised | April 1, 2025 |
July 1, 2025 | Site of Care Review | Dru408 | Added the following products to the Infusion Drug Site of Care Program; when administered by a provider, these medications will be required to be given at an approved Site of Care location:
| Revised | April 1, 2025 |
July 1, 2025 | Site of Care Review | Dru408 | Added Avtozma (tocilizumab-anoh) to the Infusion Drug Site of Care Program; when administered by a provider, this medication will be required to be given at an approved Site of Care location | Revised | June 1, 2025 |
September 1, 2025 | Blood Factors for Hemophilia A, High-Cost Extended-Half-Life (EHL) Products | Dru549 |
| Revised | June 1, 2025 |
September 1, 2025 | Blood Factors for Hemophilia B, Extended-Half-Life (EHL) Products | Dru550 | Updated not medically necessary uses to include the use of EHL blood factor products for hemophilia B in combination with non-factor prophylactic products, such as Alhemo (concizumab), Hympavzi (marstacimab), and Qfitlia (fitusiran) | Revised | June 1, 2025 |
September 1, 2025 | Complement Inhibitors | Dru385 |
| Revised | June 1, 2025 |
September 1, 2025 | Drugs for Chronic Inflammatory Diseases (Standard Formularies) | Dru888 |
| Revised | August 1, 2025 |
September 1, 2025 | Drugs for Chronic Inflammatory Diseases (Standard Plus, Metallic, Core Formularies) | Dru444 |
| Revised | August 1, 2025 |
November 1, 2025 | Complement Inhibitors | Dru385 |
| Revised | August 1, 2025 |
November 1, 2025 | Denosumab Products for Malignancy-Related Indications | Dru393 | Adding step through Wyost (denosumab-bbdz) for Bomyntra (denosumab-bnht), Osenvelt (denosumab-bmwo), and Xgeva (denosumab) new starts and continuation of therapy criteria | Revised | August 1, 2025 |
November 1, 2025 | Denosumab Products for Osteoporosis | Dru223 | Adding step through Jubbonti (denosumab-bbdz) for Conexxence (denosumab-bnht), Prolia (denosumab), and Stoboclo (denosumab-bmwo) for new starts and continuation of therapy criteria | Revised | August 1, 2025 |
November 1, 2025 | Medications for thrombocytopenia | Dru648 | Adding step through generic eltrombopag for Promacta new starts and continuation of therapy criteria | Revised | August 1, 2025 |
November 1, 2025 | Nilotinib-Containing Products | Dru151 | Adding step through generic nilotinib capsules for Tasigna, Danziten, and nilotinib d-tartrate new starts and continuation of therapy criteria; Danziten previously required step through Tasigna | Revised | August 1, 2025 |
November 1, 2025 | Provider-Administered Specialty Drugs | Dru764 |
| Revised | August 1, 2025 |
November 1, 2025 | Tolvaptan (generic, Jynarque) | Dru552 | Adding step through generic tolvaptan for Jynarque new starts and continuation of therapy criteria | Revised | August 1, 2025 |
January 1, 2026 | Drugs for chronic inflammatory diseases | Dru444 | The preferred adalimumab (Humira) products will be certain biosimilars only | Revised | April 1, 2025 |