Medication policy updates

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.

Last updated: October 1, 2025
Effective date	Policy name	Policy number	Description	New or revised	Notification date
1-May-25	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	1-Jun-25
1-Jul-25	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	1-Jun-25
1-Sep-25	Blood Factors for Hemophilia A, High-Cost Extended-Half-Life (EHL) Products	Dru549	Added step through Hemlibra (emicizumab-kxwh) for extended-half-life (EHL) products Updated not medically necessary uses to include Qfitlia (fitusiran), Hympavzi (marstacimab-hncq), and Alhemo (concizumab-mtci) when any of these products is used in combination with an EHL product	Revised	1-Jun-25
1-Sep-25	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	1-Jun-25
1-Sep-25	Complement Inhibitors	Dru385	Added requirement for primary immunoglobulin A nephropathy (IgAN) that Fabhalta (iptacopan) must be used with an ACE inhibitor or ARB and continued for reauthorization Updated investigational uses to include Fabhalta (iptacopan) when used with an endothelin receptor antagonist (ERA) for IgAN	Revised	1-Jun-25
1-Sep-25	Drugs for Chronic Inflammatory Diseases (Standard Formularies)	Dru888	Changing Steqeyma (ustekinumab-stba) and Yesintek (ustekinumab-kfce) from non-preferred to preferred and updated ustekinumab step therapy Updating continuation of therapy criteria to require step through preferred adalimumab, tocilizumab, etanercept, and ustekinumab products for corresponding non-preferred products	Revised	1-Aug-25
1-Sep-25	Drugs for Chronic Inflammatory Diseases (Standard Plus, Metallic, Core Formularies)	Dru444	Changing Steqeyma (ustekinumab-stba) and Yesintek (ustekinumab-kfce) from non-preferred to preferred and updated ustekinumab step therapy Updating continuation of therapy criteria to require step through preferred adalimumab, tocilizumab, etanercept, and ustekinumab products for corresponding non-preferred products	Revised	1-Aug-25
1-Nov-25	Complement Inhibitors	Dru385	Adding criteria for primary immunoglobulin A nephropathy (IgAN) that Fabhalta (iptacopan) must be used with ACEi/ARB and continued for reauthorization Adding investigational use of Fabhalta (iptacopan) with an endothelin receptor antagonist (ERA) for primary immunoglobulin A nephropathy (IgAN) For CD55-deficient protein-losing enteropathy (CHAPLE disease): Soliris (eculizumab) and biosimilars Bkemv (eculizumab-aeeb) and unbranded eculizumab-aagh will require step through Epysqli (eculizumab-aagh) For refractory myasthenia gravis (MG): Soliris (eculizumab) and biosimilars Bkemv (eculizumab-aeeb) and unbranded eculizumab-aagh will require step through Epysqli (eculizumab-aagh) or Ultomiris (ravulizumab-cwvz)	Revised	1-Aug-25
1-Nov-25	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	1-Aug-25
1-Nov-25	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	1-Aug-25
1-Nov-25	Medications for thrombocytopenia	Dru648	Adding step through generic eltrombopag for Promacta new starts and continuation of therapy criteria	Revised	1-Aug-25
1-Nov-25	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	1-Aug-25
1-Nov-25	Provider-Administered Specialty Drugs	Dru764	Adding the following ustekinumab biosimilars to policy: Imuldosa (ustekinumab-srlf), Steqeyma (ustekinumab-stba), Yesintek (ustekinumab-kfce) and Wezlana (ustekinumab-auub) Adding the following denosumab biosimilars to policy: Jubbonti (denosumab-bbdz) and Wyost (denosumab-bbdz) Adding Hercessi (trastuzumab-strf), a trastuzumab biosimilar, to policy Adding the following eculizumab biosimilars to policy: epysqli (eculizumab-aagh) and Bkemv (eculizumab-aeeb)	Revised	1-Aug-25
1-Nov-25	Tolvaptan (generic, Jynarque)	Dru552	Adding step through generic tolvaptan for Jynarque new starts and continuation of therapy criteria	Revised	1-Aug-25
1-Jan-26	Drugs for Chronic Inflammatory Diseases (Standard Plus Formulary)	Dru444	Hadlima (adalimumab-bwwd) moved to non-preferred, which requires a step through all preferred adalimumab products. Note that preferred adalimumab products include: adalimumab-aaty and adalimumab-adbm (NDCs beginning with 82009).	Revised	1-Oct-25
1-Jan-26	Medications for Epidermolysis Bullosa	Dru759	Vyjuvek (beremagene geperpavec-svdt) and/or Filsuvez (birch triterpenes), as a sole treatment or in combination, are considered investigational when used on a treatment area previously treated with Zevaskyn (prademagene zamikeracel). The concomitant use of Vyjuvek (beremagene geperpavec-svdt) and/or Filsuvez (birch triterpenes) with Zevaskyn (prademagene zamikeracel) on the same treatment site is considered investigational. The concomitant use of Vyjuvek (beremagene geperpavec-svdt) and Filsuvez (birch triterpenes) at the same treatment site for any indication is considered investigational.	Revised	1-Oct-25
1-Jan-26	Medications for Hereditary Angioedema	Dru535	For new plan members, continuation of therapy will now require documentation of prior coverage. For new plan members, prophylactic HAE medications will not be coverable for Type III HAE.	Revised	1-Oct-25
1-Jan-26	Non-Preferred Blood Glucose Test Strips and Blood Glucose Meters	Dru505	Updating preferred products to Ascensia (Contour) and Abbott (Freestyle, Precision) lines of products. LifeScan OneTouch products will now be non-preferred.	Revised	1-Oct-25
1-Jan-26	Non-Preferred Drugs	Dru760	Removing the following branded products from the policy since they have been or will be removed from the market: Adlyxin, Flovent Diskus, Flovent HFA, Kazano, Nesina, Oseni and Semglee.	Revised	1-Oct-25
1-Jan-26	Products with Therapeutically Equivalent Biosimilars/Reference Products	Dru620	Updating preferred products Updating the preferred pegfilgrastim products to Fylnetra and Fulphila. Nyvepria will now be non-preferred. Updating the preferred rituximab products to Ruxience, Riabni and Truxima. Updating the preferred trastuzumab products to Kanjinti, Ontruzant and Trazimera.	Revised	1-Oct-25
1-Jan-26	Site of Care Review	Dru408	Adding Imaavy (nipocalimab-aahu) to policy. Authorization period for members with Kawasaki disease or difficult IV access shortened to three months. Clarifying intent of behavioral issue exception and infusion-reaction criteria. Reauthorization review will be required every 12 months (excluding cases for short-term medical reasons).	Revised	1-Oct-25
1-Jan-26	Synagis, palivizumab, Respiratory syncytial virus (RSV) immune prophylaxis	Dru029	Updating step therapy on Synagis (palivizumab) to require both Beyfortus (nirsevimab-alip) and new FDA approved Enflonsia (clesrovimab-cfor) to be unavailable, contraindicated, or not tolerated.	Revised	1-Oct-25
1-Jan-26	Yondelis, trabectedin	Dru440	Adding criteria limiting use in patients with leiomyosarcoma in the subsequent line setting to those without progression on prior Yondelis therapy.	Revised	1-Oct-25