Florida Blue

Example 2: Eye injection, Lucentis ( ) requires prior auth listed below which the corresponding administration CPT code, , would be identified as a supportive

GamaSTAN S/D IMMUNE GLOBULIN 12/15/1999 n/a

CARIMUNE NF IMMUNE GLOBULIN 12/15/1999 n/a

CUVITRU IMMUNE GLOBULIN x SAD** 10/06/2016 n/a

SYNAGIS PALIVIZUMAB 01/01/2008 n/a

* Unlisted IVIG* IMMUNE GLOBULIN 01/01/1999 n/a

Example 1: Oncology drug, Yervoy ( ) requires prior auth listed below which the corresponding administration CPT code, , would be identified as a supportive

* ORAL ORAL MUCOADHESIVE, ANY TYPE* BOTH*** 10/01/2023 n/a

LUTATHERA LUTETIUM LU 177 x 01/26/2018 n/a

ZEVALIN IBRITUMOMAB TIUXETAN x 07/01/2009 n/a

AZEDRA IODINE I-131 IOBENGUANE x 08/01/2018 n/a

METASTRON STRONTIUM SR-89 CHLORIDE x 01/01/2019 n/a

QUADRAMET SAMARIUM SM-153 LEXIDRONAM x 01/01/2019 n/a

XOFIGO RADIUM RA 223 DICHLORIDE x 05/15/2013 n/a

PLUVICTO LUTETIUM (177LU) VIPIVOTIDE x 03/23/2022 n/a

* Unclassified Rx* UNCLASSIFED RADIOPHARMACEUTICAL* x 01/01/2003 n/a

CABLIVI CAPLACIZUMAB-YHDP BOTH*** 03/15/2019 n/a

DATROWAY DATOPOTAMAB DERUXTECAN-DLNK x 01/17/2025 n/a

AVASTIN (non- BEVACIZUMAB 12/15/2012 06/30/2015

ZIIHERA ZANIDATAMAB-HRII x 11/21/2024 n/a

IMAAVY NIPOCALIMAB-AAHU x 04/29/2025 n/a New HCPCS, effective 01/01/2026

EMRELIS TELISOTUZUMAB VEDOTIN-TLLV x 05/14/2025 n/a New HCPCS, effective 01/01/2026

LYNOZYFIC LINVOSELTAMAB-GCPT x 07/02/2025 n/a

KYXATA CARBOPLATIN x 08/08/2025 n/a

ADALIMUMAB-AACF ADALIMUMAB-AACF x SAD** 07/02/2023 n/a

OPFOLDA & OPFOLDA & POMBILITI ADM 04/01/2024 n/a

SPRAVATO ESKETAMINE 03/06/2019 n/a

ORENCIA IV ABATACEPT x x 01/01/2014 n/a

HUMIRA ADALIMUMAB x SAD** 01/01/2005 n/a

ADUHELM ADUCANUMAB-AVWA x 06/07/2021 n/a HCPCS Termed 12/31/2025

LEQEMBI LECANEMAB-IRMB x 01/06/2023 n/a

KISUNLA DONANEMAB-AZBT x 07/02/2024 n/a

EYLEA HD AFLIBERCEPT x 08/18/2023 n/a

EYLEA AFLIBERCEPT x 11/21/2011 n/a

BEOVU BROLUCIZUMAB-DBLL x 10/08/2019 n/a

FABRAZYME AGALSIDASE BETA x 07/01/2016 n/a

CINVANTI APREPITANT x 01/02/2018 n/a

LEMTRADA ALEMTUZUMAB x 11/21/2014 n/a

PEDMARK SODIUM THIOSULFATE 10/03/2022 n/a

AMEVIVE ALEFACEPT 10/15/2008 12/31/2014 product no longer available

LAMZEDE VELMANASE ALFA-TYCV x 04/13/2023 n/a

XENPOZYME OLIPUDASE-ALFA x 08/31/2022 n/a

NEXVIAZYME AVALGLUCOSIDASE ALFA-NGPT x 08/06/2021 n/a

MYOZYME ALGLUCOSIDASE ALFA 01/01/2016 n/a

LUMIZYME ALGLUCOSIDASE ALFA x 01/01/2016 n/a

ONPATTRO PATISIRAN x 08/10/2018 n/a

GIVLAARI GIVOSIRAN 12/15/2019 n/a

OXLUMO LUMASIRAN 12/01/2020 n/a

AMVUTTRA VUTRISIRAN 06/13/2022 n/a

ARALAST ALPHA 1-PROTEINASE INHIBITOR x 01/01/2005 n/a

GLASSIA ALPHA 1-PROTEINASE INHIBITOR x 10/11/2010 n/a

APOKYN APOMORPHINE HYDROCHLORIDE BOTH*** 01/01/2019 n/a

BAL IN OIL DIMERCAPROL x 08/15/2001 n/a

BENLYSTA IV BELIMUMAB IV x 03/10/2011 n/a

SAPHNELO ANIFROLUMAB-FNIA x 07/30/2021 n/a

FASENRA BENRALIZUMAB x 11/14/2017 n/a

ZINPLAVA BEZLOTOXUMAB x 12/08/2016 n/a

BRINEURA CERLIPONASE ALFA x 04/27/2017 n/a

PROBUPHINE BUPRENORPHINE IMPLANT x 06/06/2016 n/a

BRIXADI BUPRENORPHINE EXTENDED-RELEASE 05/24/2023 n/a

BRIXADI BUPRENORPHINE EXTENDED-RELEASE 05/24/2023 n/a

CRYSVITA BUROSUMAB-TWZA x 04/17/2018 n/a

BOTOX ONABOTULINUMTOXIN A x 10/01/1999 n/a

DYSPORT ONABOTULINUMTOXIN A x 11/02/2009 n/a

MYOBLOC ONABOTULINUMTOXIN B x 12/11/2000 n/a

XEOMIN ONABOTULINUMTOXIN A x 12/11/2000 n/a

DAXXIFY DAXIBOTULINUMTOXIN A-LANM x 08/11/2023 n/a

KYBELLA DEOXYCHOLIC ACID 07/27/2016 n/a

TAKHZYRO LANADELUMAB-FLYO x SAD** 08/27/2018 n/a

RUCONEST C1 ESTERASE INHIBITOR x SAD** 09/05/2014 n/a

BERINERT C1 ESTERASE INHIBITOR x x BOTH*** 10/15/2009 n/a

CINRYZE C1 ESTERASE INHIBITOR x SAD** 07/15/2009 n/a

HAEGARDA C-1 ESTERASE INH x SAD** 07/17/2017 n/a

CALCIUM EDTA EDETATE CALCIUM DISODIUM x 08/15/2001 n/a

RENVELA (ESRD) SEVELAMER CARBONATE (ESRD) SAD** 01/01/2025 n/a

RENVELA (ESRD) SEVELAMER CARBONATE (ESRD) SAD** 01/01/2025 n/a

RENAGEL (ESRD) SEVELAMER HYDROCHLORIDE (ESRD) SAD** 01/01/2025 n/a

VELPHORO (ESRD) SUCROFERRIC OXYHYDROXIDE (ESRD) SAD** 01/01/2025 n/a

FOSRENOL (ESRD) LANTHANUM CARBONATE (ESRD) SAD** 01/01/2025 n/a

FOSRENOL (ESRD) LANTHANUM CARBONATE (ESRD) SAD** 01/01/2025 n/a

AURYXIA (ESRD) FERRIC CITRATE (ESRD) SAD** 01/01/2025 n/a

CALCIUM ACETATE CALCIUM ACETATE (ESRD) SAD** 01/01/2025 n/a

ILARIS CANAKINUMAB x 10/15/2013 n/a

FUSILEV LEVOLEUCOVORIN x 04/01/2015 n/a

KHAPZORY LEVOLEUCOVORIN x 10/01/2019 n/a

CIMZIA CERTOLIZUMAB PEGOL x x BOTH*** 04/22/2008 n/a

NOVAREL CHORIONIC GONADOTROPIN x SAD** 11/13/2000 n/a infertility benefit review

YEZTUGO (inj) LENACAPAVIR (inj) 06/18/2025 n/a

YEZTUGO (oral) LENACAPAVIR (oral) SAD** 06/18/2025 n/a

XIAFLEX COLLAGENASE, CLOST HIST x 01/01/2016 n/a

ADAKVEO CRIZANLIZUMAB x 11/20/2019 n/a

YEZTUGO LENACAPAVIR 06/18/2025 n/a

HP ACTHAR CORTICOTROPIN x SAD** 01/07/2013 n/a

PURIFIED CORTROPHIN x SAD** 12/01/2021 n/a

RYTELO IRNETELSTAT x 06/06/2024 n/a

KORSUVA DIFELIKEFALIN 04/01/2022 n/a

ARANESP DARBEPOETIN ALFA x BOTH*** 01/01/2014 n/a

ARANESP DARBEPOETIN ALFA BOTH*** 01/01/2014 n/a

EPOGEN EPOETIN ALFA x BOTH*** 01/01/2014 n/a

EPOGEN EPOETIN ALFA BOTH*** 01/01/2014 n/a

MIRCERA EPOETIN BETA (ESRD use) BOTH*** 10/01/2014 n/a

MIRCERA EPOETIN BETA (non- ESRD use) x BOTH*** 10/01/2014 n/a

DUVROQ DAPRODUSTAT (ESRD use) 10/01/2023 n/a HCPCS Termed 12/31/2025

REBLOZYL LUSPATERCEPT-AAMT x 11/08/2019 n/a

PROLIA DENOSUMAB x 06/05/2010 n/a

VAFSEO (ESRD) VADADUSTAT (ESRD) SAD** 01/01/2025 n/a

TESTOSTERONE CYPIONATE x BOTH*** 06/15/2010 06/30/2019

AZMIRO TESTOSTERONE CYPIONATE x SAD** 12/02/2024 n/a

TESTOPEL TESTOSTERONE PELLETS 06/15/2010 n/a

QUZYTTIR CETIRIZINE HYDROCHLORIDE 07/01/2024 n/a

OPFOLDA MIGLUSTAT 04/01/2024 n/a

POMBILITI CIPAGLUCOSIDASE ALFA-ATGA x 09/28/2023 n/a

UNITUXIN DINUTUXIMAB x 05/01/2017 n/a

KALBITOR ECALLANTIDE x BOTH*** 12/16/2009 n/a

SOLIRIS ECULIZUMAB x 03/15/2010 n/a

RADICAVA EDARAVONE x 05/05/2017 n/a

ENJAYMO SUTIMLIMAB-JOME x 02/04/2022 n/a

ULTOMIRIS RAVULIZUMAB-CWVZ x 12/21/2018 n/a

QALSODY TOFERSEN 04/25/2023 n/a

EVKEEZA EVINACUMAB-DGNB x 02/16/2021 n/a

LEQVIO INCLISIRAN 12/23/2021 n/a

PIASKY CROVALIMAB-AKKZ x 06/20/2024 n/a

VIMIZIM ELOSULFASE ALFA x 02/14/2014 n/a

ELREXFIO ELRANATAMAB-BCMM x 08/14/2023 n/a

FLOLAN EPOPROSTENOL x 11/15/2009 n/a

VYLOY ZOLBETUXIMAB-CLZB x 10/18/2024 n/a

HEMGENIX ETRANACOGENE DEZAPARVOVEC-DRLB 11/28/2022 n/a

ROCTAVIAN VALOCTOCOGENE ROXAPARVOVEC- 06/29/2023 n/a

ELEVIDYS DELANDISTROGENE MOXEPARVOVEC 06/22/2023 n/a

BEQVEZ FIDANACOGENE ELAPARVOVEC-DZKT 04/26/2024 n/a

AMONDYS 45 CASIMERSEN 02/25/2021 n/a

VILTEPSO VILTOLARSEN 09/01/2020 n/a

EXONDYS 51 ETEPLIRSEN x 09/19/2016 n/a

VYONDYS 53 GOLODIRSEN 12/12/2019 n/a

FOCINVEZ FOSAPREPITANT 07/01/2025 n/a

MONOFERRIC FERRIC DERISOMALTOSE 10/01/2020 n/a

ENBREL ETANERCEPT x SAD** 04/15/2001 n/a

INJECTAFER FERRIC CARBOXYMALTOSE x 07/25/2013 n/a

REBYOTA FECAL MICROBIOTA, LIVE-JSLM x 01/09/2023 n/a

NEUPOGEN FILGRASTIM x BOTH*** 11/15/2000 n/a

TRIFERIC AVNU FERRIC PYROPHOSPHATE CITRATE 10/01/2021 n/a HCPCS Termed 12/31/2025

GRANIX TBO-FILGRASTIM x BOTH*** 11/11/2013 n/a

COSELA TRILACICLIB 02/22/2021 n/a

ROLVEDON EFLAPEGRASTIM-XNST x 09/09/2022 n/a

EMEND FOSAPREPITANT x 11/14/2016 06/30/2021

AKYNZEO FOSNETUPITANT x 05/08/2018 n/a

NAGLAZYME GALSULFASE x 01/01/2016 n/a

PRIVIGEN HUMAN IMMUNE GLOBULIN x 01/01/2008 n/a

CUTAQUIG IMMUNE GLOBULIN x SAD** 05/13/2019 n/a

ALYGLO HUMAN IMMUNE GLOBULIN x 03/08/2024 n/a

ASCENIV IMMUNE GLOBULIN IV x 10/01/2019 n/a

CUVITRU IMMUNE GLOBULIN x SAD** 10/06/2016 n/a

BIVIGAM HUMAN IMMUNE GLOBULIN x 12/19/2012 n/a

GAMMAPLEX HUMAN IMMUNE GLOBULIN x 03/31/2010 n/a

XEMBIFY IMMUNE GLOBULIN SQ x SAD** 11/01/2019 n/a

HIZENTRA HUMAN IMMUNE GLOBULIN x SAD** 04/01/2010 n/a

GAMMAKED HUMAN IMMUNE GLOBULIN x x BOTH*** 08/03/2011 n/a

VIVAGLOBIN HUMAN IMMUNE GLOBULIN 03/01/2006 n/a HCPCS Termed 12/31/2025

CARIMUNE NF HUMAN IMMUNE GLOBULIN x 12/15/1999 n/a

OCTAGAM HUMAN IMMUNE GLOBULIN x 05/24/2004 n/a

GAMMAGARD LIQUID HUMAN IMMUNE GLOBULIN x x BOTH*** 07/01/2005 n/a

FLEBOGAMMA HUMAN IMMUNE GLOBULIN x 01/11/2004 n/a

HYQVIA IMMUNE GLOBULIN x SAD** 10/06/2014 n/a

PANZYGA IMMUNE GLOBULIN IV x 09/02/2019 n/a

COPAXONE GLATIRAMER x SAD** 10/01/2011 n/a

QIVIGY IMMUNE GLOBULIN IV x 09/26/2025 n/a

SIMPONI ARIA GOLIMUMAB x 07/25/2013 n/a

SUSTOL GRANISETRON x 10/04/2016 n/a

TREMFYA SQ GUSELKUMAB x SAD** 07/14/2017 n/a

ZULRESSO BREXANOLONE 06/18/2019 n/a

FRAGMIN DALTEPARIN SODIUM SAD** 03/15/2001 12/31/2014

LOVENOX ENOXAPARIN SODIUM SAD** 07/15/2001 12/31/2014

ARIXTRA FONDAPARINUX SODIUM SAD** 10/15/2005 12/31/2014

MAKENA HYDROXYPROGESTERONE CAPROATE x 02/11/2011 n/a

HYDROXY- HYDROXYPROGESTERONE CAPROATE x 06/09/2016 n/a

BONIVA IBANDRONATE SODIUM x 12/15/2007 02/14/2021

ELAPRASE IDURSULFASE x 01/01/2016 n/a

FIRAZYR ICATIBANT x SAD** 08/25/2011 n/a

REMICADE INFLIXIMAB x 04/25/2001 n/a

SPEVIGO SPESOLIMAB x 09/01/2022 n/a

ZYMFENTRA INFLIXIMAB-DYYB x SAD** 10/23/2023 n/a

CEREZYME IMUGLUCERASE x 04/15/2002 n/a

NULIBRY FOSDENOPTERIN BOTH*** 02/26/2021 n/a

UPLIZNA INEBILIZUMAB-CDON x 07/10/2020 n/a

AVONEX INTERFERON BETA-1A x SAD** 10/01/2011 n/a

BETASERON INTERFERON BETA-1B x SAD** 10/01/2011 n/a

SOMATULINE DEPOT LANREOTIDE x 04/15/2010 n/a

ALDURAZYME LARONIDASE x 01/01/2016 n/a

CIPLA LANREOTIDE x 10/01/2022 n/a

FUROSCIX FUROSEMIDE SAD** 10/22/2022 n/a

LUPRON DEPOT LEUPROLIDE ACETATE x 01/01/2005 n/a

FENSOLVI LEUPROLIDE ACETATE 05/04/2020 n/a

CAMCEVI LEUPROLIDE x 01/01/2021 n/a

LUTRATE LEUPROLIDE DEPOT x 01/01/2023 n/a

INCRELEX MECASERMIN x SAD** 06/15/2006 n/a

NUCALA MEPOLIZUMAB x BOTH*** 11/30/2015 n/a

RELISTOR METHYLNALTREXONE x SAD** 01/01/2009 n/a

OMVOH IV MIRIKIZUMAB-MRKZ IV x 10/26/2023 n/a

APHEXDA MOTIXAFORTIDE 08/08/2023 n/a

VIVITROL NALTREXONE 09/15/2008 12/31/2015

TYSABRI NATALIZUMAB x 03/15/2008 n/a

SPINRAZA NUSINERSEN 12/28/2016 n/a

SKYRIZI IV RISANKIZUMAB-RZAA x 06/16/2022 n/a

BRIUMVI UBLITUXIMAB x 12/28/2022 n/a

OCREVUS OCRELIZUMAB x 03/28/2017 n/a

OCREVUS ZUNOVO OCRELIZUMAB; HYALURONIDASE-OCSQ x 09/13/2024 n/a

SANDOSTATIN LAR OCTREOTIDE x 03/15/2009 n/a

NEUMEGA OPRELVEKIN x SAD** 11/15/2000 n/a

TEZSPIRE TEZEPELUMAB-EKKO x 12/17/2021 n/a

XOLAIR OMALIZUMAB x BOTH*** 12/15/2004 n/a

POSFREA PALONOSETRON HYDROCHLORIDE 07/01/2025 n/a

ALOXI PALONOSETRON x 02/15/2009 10/31/2021

SIGNIFOR LAR PASREOTIDE LONG ACTING x BOTH*** 02/17/2015 n/a

MACUGEN PEGAPTANIB SODIUM x 01/01/2005 n/a

NEULASTA PEGFILGRASTIM x BOTH*** 04/01/2002 n/a

KRYSTEXXA PEGLOTICASE x 01/01/2016 n/a

ELFABRIO PEGUNIGALSIDASE ALFA-IWXJ x 05/09/2023 n/a

MOZOBIL PLERIXAFOR x 07/15/2012 n/a

Progesterone in Oil PROGESTERONE 05/15/2011 n/a

CEPROTIN PROTEIN C CONCENTRATE x 12/15/2013 n/a

VABYSMO FARICIMAB-SVOA x 01/28/2022 n/a

Example 2: Eye injection, Lucentis ( ) requires prior auth listed below which the corresponding administration CPT code, , would be identified as a supportive

SUSVIMO RANOBIZUMAB x 10/22/2021 n/a

SYFOVRE PEGCETACOPLAN SAD** 02/27/2023 n/a

IZERVAY AVACINCAPTAD PEGOL 08/04/2023 n/a

ELITEK RASBURICASE x 01/01/2016 n/a

CINQAIR RESLIZUMAB x 04/01/2016 n/a

PHOTREXA VISCOUS RIBOFLAVIN 5-PHOSPHATE x 07/01/2017 n/a

HYPER RHO SD Mini RHO D IMMUNE GLOBULIN 01/01/2008 06/30/2015

HYPER RHO SD RHO D IMMUNE GLOBULIN 01/01/2008 06/30/2015

RHOPHYLAC RHO D IMMUNE GLOBULIN 01/01/2008 06/30/2015

WINRHO SDF RHO D IMMUNE GLOBULIN 01/01/2008 06/30/2015

ARCALYST RILONACEPT x SAD** 10/15/2013 n/a

VARUBI ROLAPITANT x 11/15/2017 n/a

NPLATE ROMIPLOSTIM x 03/15/2009 n/a

LEUKINE SARGRAMOSTIM (GM-CSF) x BOTH*** 11/14/2016 n/a

KANUMA SEBELIPASE ALFA x 12/08/2015 n/a

SYLVANT SILTUXIMAB x 04/25/2014 n/a

GENOTROPIN SOMATROPIN x SAD** 11/15/2000 n/a

RYPLAZIM PLASMINOGEN, HUMAN-TVMH x BOTH*** 06/04/2021 n/a

AJOVY FREMANEZUMAB-VRFRM x SAD** 09/17/2018 n/a

VYEPTI EPTINEZUMAB-JJMR x 02/21/2020 n/a

TALVEY TALQUETAMAB-TGVS x 08/09/2023 n/a

ELELYSO TALIGLUCERASE ALFA x 05/08/2012 n/a

BONSITY TERIPARATIDE x SAD** 06/09/2025 n/a

EVENITY ROMOSOZUMAB-AQQG x 04/16/2019 n/a

DELATESTRYL TESTOSTERONE ENANTHATE x BOTH*** 06/15/2010 06/30/2019

AVEED TESTOSTERONE UNDECANOATE x 03/10/2014 n/a

TEPEZZA TEPROTUMUMAB-TRBW x 01/28/2020 n/a

ILUMYA TILDRAKIZUMAB-ASMN x 09/17/2018 n/a

COSENTYX IV EXAGAMGLOGENE AUTOTEMCEL IV x 10/25/2023 n/a

ACTEMRA IV TOCILIZUMAB IV x 01/18/2010 n/a

LOQTORZI TORIPALIMAB-TPZI x 10/27/2023 n/a

REMODULIN TREPROSTINIL x SAD** 05/23/2002 n/a

XIPERE TRIAMCINOLONE ACETONIDE 11/29/2021 n/a

ZILRETTA TRIAMCINOLONE x 10/23/2017 n/a

TRELSTAR DEPOT TRIPTORELIN PAMOATE x 01/01/2005 n/a

TRIPTODUR TRIPTORELIN ER x 09/22/2017 n/a

BRAVELLE UROFOLLITROPIN x SAD** 05/27/2002 n/a HCPCS Termed 12/31/2025

STELARA SQ USTEKINUMAB x x BOTH*** 09/25/2009 n/a

STELARA IV USTEKINUMAB IV x 09/27/2016 n/a

ENTYVIO VEDOLIZUMAB x 05/21/2014 n/a

VPRIV VELAGLUCERASE ALFA x 04/15/2002 n/a

SKYSONA ELIVALDOGENE AUTOTEMCEL 09/16/2022 n/a

ZEVASKYN PRADEMAGENE ZAMIKERACEL 04/29/2025 n/a New HCPCS, effective 01/01/2026

LENMELDY ATIDARSAGENE AUTOTEMCEL 03/18/2024 n/a

CASGEVY EXAGAMGLOGENE AUTOTEMCEL 12/08/2023 n/a

ZYNTEGLO BETIBEGLOGENE AUTOTEMCEL 08/17/2022 n/a

LYFGENIA LOVOTIBEGLOGENE AUTOTEMCEL 12/08/2023 n/a

VISUDYNE VERTEPORFIN x 04/12/2000 n/a

MEPSEVII VESTRONIDASE ALFA-VJBK x 11/15/2017 n/a

LUXTURNA VORETIGENE NEPARVOVEC-RZYL 01/03/2018 n/a

ZOLGENSMA ONASEMNOGENE ABEPARVOVEC-XIOI 05/24/2019 n/a

VYJUVEK BEREMAGENE GEPERPAVEC-SVDT x 05/19/2023 n/a

RYONCIL REMESTEMCEL-L-RKND x 12/18/2024 n/a

ENCELTO REVAKINAGENE TARORETCEL-LWEY 03/06/2025 n/a

B-12 CYANOCOBALAMIN BOTH*** 03/15/2001 06/30/2014

ZOMETA/ RECLAST ZOLEDRONIC ACID x 02/15/2008 02/15/2021

AIMOVIG ERENUMAB-AOOE x SAD** 05/17/2018 n/a

EDTA edetate disodium 08/15/2001 n/a

INBRIJA LEVODOPA x SAD** 02/25/2019 n/a

ACTEMRA SQ TOCILIZUMAB SQ x SAD** 10/21/2013 n/a

* NOC ESRD DRUG NOC ESRD DRUG BOTH*** 01/01/2019 n/a

HEMLIBRA EMICIZUMAB-KXWH x SAD** 11/16/2017 n/a

ADZYNMA ADAMTS13, RECOMBINANT-KRHN x 11/09/2023 n/a

HYMPAVZI MARSTACIMAB-HNCQ x SAD** 10/11/2024 n/a

ALHEMO CONCIZUMAB-MTCI SAD** 12/20/2024 n/a New HCPCS, effective 10/01/2025

QFITLIA FITUSIRAN SAD** 03/28/2025 n/a New HCPCS, effective 10/01/2025

COAGADEX FACTOR X x SAD** 12/01/2015 n/a

FIBRYGA HUMAN FIBRINOGEN CONCENTRATE x BOTH*** 12/27/2017 n/a

RIASTAP HUMAN FIBRINOGEN CONCENTRATE x BOTH*** 03/24/2009 n/a

VONVENDI VON WILLEBRAND FACTOR x SAD** 07/05/2016 n/a

CORIFACT FACTOR XIII CONCENTRATE x SAD** 04/04/2011 n/a

TRETTEN FACTOR XIII A-SUBUNIT x SAD** 03/14/2014 n/a

NOVOEIGHT FACTOR VIII x SAD** 04/02/2015 n/a

WILATE VON WILLEBRAND FACTOR x SAD** 01/01/2010 n/a

XYNTHA FACTOR VIII x SAD** 07/10/2008 n/a

ALPHANATE VWF FACTOR VIII/ VON WILLEBRAND FACTOR x SAD** 03/15/2001 n/a

HUMATE P VON WILLEBRAND FACTOR COMPLEX x SAD** 03/15/2001 n/a

OBIZUR FACTOR VIII (RECOMBINANT) x SAD** 11/17/2014 n/a

NOVOSEVEN RT FACTOR VIIA (RECOMBINANT) x SAD** 03/15/2001 n/a

HEMOFIL M FACTOR VIII x SAD** 06/14/2001 n/a

ADVATE FACTOR VIII x SAD** 07/25/2003 n/a

ALPHANINE FACTOR IX x SAD** 03/15/2001 n/a

PROFILNINE SD FACTOR IX x SAD** 03/15/2001 n/a

BENEFIX FACTOR IX x SAD** 03/15/2001 n/a

FEIBA ANTI-INHIBITOR COAGUALTION x SAD** 03/15/2001 n/a

* Unclassified FACTOR HEMOPHILIA CLOTTING FACTOR, NOT x SAD** 03/15/2001 n/a

RIXUBIS FACTOR IX x SAD** 10/02/2013 n/a

ALPROLIX FACTOR IX x SAD** 04/18/2014 n/a

IDELVION FACTOR IX x SAD** 03/04/2016 n/a

REBINYN FACTOR IX, GLYCOPEGYLATED x SAD** 11/20/2017 n/a

ESPEROCT FACTOR VIII, GLYCOPEGYLATED-EXEI x SAD** 02/03/2020 n/a

ELOCTATE FACTOR VIII x SAD** 07/14/2014 n/a

ADYNOVATE FACTOR VIII, PEGYLATED x SAD** 12/01/2015 n/a

JIVI FACTOR VIII, PEGYLATED-AUCI x SAD** 08/30/2018 n/a

NUWIG FACTOR VIII x SAD** 11/01/2015 n/a

AFSTYLA FACTOR VIII x SAD** 05/25/2016 n/a

KOVALTRY FACTOR VIII x SAD** 03/16/2016 n/a

SEVENFACT FACTOR VIIA-JNCW SAD** 09/01/2020 n/a

IXINITY FACTOR IX x SAD** 05/29/2015 n/a

ALTUVIIIO HEMOPHILIA CLOTTING FACTOR, NOT x SAD** 02/22/2023 n/a

RETISERT FLUCINOLONE ACETONIDE x 05/15/2015 n/a

OZURDEX DEXAMETHASONE x 05/15/2015 n/a

ILUVIEN FLUOCINOLONE ACETONIDE x 12/01/2014 n/a

YUTIQ FLUOCINOLONE ACETONIDE x 12/17/2018 n/a

DUROLANE HYALURONAN DERIVATIVE x 11/09/2017 n/a

GENVISC 850 HYALURONAN/ DERIVATIVE x 01/01/2016 n/a

HYALGAN SODIUM HYALURONATE x 06/15/2000 n/a

HYMOVIS HYALURONAN/ DERIVATIVE x 11/12/2015 n/a

EUFLEXXA SODIUM HYALURONATE x 10/24/2005 n/a

ORTHOVISC HIGH MOLECULAR WEIGHT x 03/01/2004 n/a

SYNVISC HYLAN G-F 20 x 06/15/2000 n/a

GEL-ONE CROSS-LINKED HYALURONATE x 11/01/2012 n/a

MONOVISC HIGH MOLECULAR WEIGHT x 04/16/2014 n/a

GEL-SYN HYALURONAN/ DERIVATIVE x 01/01/2016 n/a

TRIVISC HYALURONAN DERIVATIVE x 09/10/2018 n/a

MACI AUTOLOGOUS CULTURED 01/01/2017 n/a

SYNOJOYT SYNOJOYNE x 10/01/2019 n/a

TRILURON TRILURON x 10/01/2019 n/a

VISCO-3 SODIUM HYALURONATE x 05/01/2017 n/a Rx previously assigned to HCPCS

SCENESSE AFAMELANOTIDE 10/08/2019 n/a

YCANTH CANTHARIDIN 07/21/2023 n/a

IDOSE TR TRAVOPROST INTRACAMERAL 12/13/2023 n/a

SINUVA IMPLANT MOMETASONE FUROATE x 02/15/2018 n/a

MYHIBBIN MYCOPHENOLATE MOFETIL SAD** 01/01/2025 n/a

OHTUVAYRE ENSIFENTRINE SAD** 01/01/2025 n/a

TYVASO TREPROSTINIL INHALATION x SAD** 08/14/2009 n/a

* NOC INHALATION NOC INHALATION SOLUTION, DME x SAD** 01/13/1993 n/a

* NOC OTHER THAN NOC OTHER THAN INHALATION DRUGS, x SAD** 01/13/1993 n/a

* NOC (FINAL NOC (FINAL COMPOUNDED PRODUCT) BOTH*** 01/01/2016 n/a

MACRILEN MACIMORELIN 07/23/2018 n/a

XELODA CAPECITABINE x SAD** 10/01/2024 n/a

IRESSA GEFITINIB x SAD** 09/15/2015 n/a

JYLAMVO METHOTREXATE x SAD** 07/01/2024 n/a

XATMEP METHOTREXATE x SAD** 07/01/2024 n/a

AKYNZEO NETUPITANT and PALONOSETRON x SAD** 04/01/2017 n/a

TEMODAR TEMOZOLOMIDE x SAD** 01/01/2012 n/a

HYCAMTIN ORAL TOPOTECAN x SAD** 05/15/2009 n/a

* Oral Chemo ORAL CHEMO PRESCRIPTION DRUG x SAD** 12/21/1994 n/a

DATROWAY DATOPOTAMAB DERUXTECAN-DLNK x 01/17/2025 n/a

ERWINAZE ASPARAGINASE x 07/15/2012 n/a HCPCS Termed 12/31/2025

RYLAZE ASPARAGINASE ERWINIA x 06/30/2021 n/a

TECENTRIQ ATEZOLIZUMAB x 05/18/2016 n/a

BAVENCIO AVELUMAB x 03/23/2017 n/a

TECENTRIQ HYBREZA x 09/12/2024 n/a

VIDAZA AZACITIDINE x 04/01/2015 n/a

IMDELLTRA TARLATAMAB-DLLE x 05/16/2024 n/a

ANKTIVA NOGAPENDEKIN ALFA INBAKICEPT-PMLN x 04/22/2024 n/a

ADSTILADRIN NADOFARAGENE FIRADENOVEC-VNCG x 12/16/2022 n/a

BELEODAQ BELINOSTAT x 07/21/2014 n/a

TREANDA BENDAMUSTINE x 04/01/2015 n/a

BENDEKA BENDAMUSTINE x 12/11/2015 n/a

AVASTIN (oncology BEVACIZUMAB x 07/20/2009 n/a

BELRAPZO BENDAMUSTINE HCI x 05/15/2018 n/a

NIKTIMVO AXATILIMAB-CSFR x 08/14/2024 n/a

BLINCYTO BLINATUMOMAB x 12/16/2014 n/a

VELCADE BORTEZOMIB x 04/01/2013 08/15/2025

ADCETRIS BRENTUXIMAB x 08/25/2011 n/a

JEVTANA CABAZITAXEL x 07/15/2010 n/a

CARBOPLATIN CARBOPLATIN 04/15/2009 12/31/2014

BORTEZOMIB BORTEZOMIB x 01/01/2023 08/15/2025

KYPROLIS CARFILZOMIB x 07/20/2012 n/a

BORTEZOMIB BORTEZOMIB x 01/01/2023 08/15/2025

BORTEZOMIB BORTEZOMIB x 01/01/2023 08/15/2025

BORUZU BORTEZOMIB x 04/01/2025 n/a

ERBITUX CETUXIMAB x 04/01/2013 n/a

VIVIMUSTA BENDAMUSTINE HYDROCHLORIDE x 12/07/2022 n/a

ALIQOPA COPANLISIB x 09/18/2017 n/a

BENDAMUSTINE BENDAMUSTINE x 07/01/2023 n/a

BENDAMUSTINE BENDAMUSTINE x 07/01/2023 n/a

RYBREVANT AMIVANTAMAB-VMJW x 05/21/2021 n/a

ELAHERE MIRVETUXIMAB SORAVTANSINE-GYNX x 11/28/2022 n/a

CABAZITAXEL CABAZITAXEL x 10/01/2023 n/a

ASPARLAS CALASPARGASE PAGOL-MKNL x 10/01/2019 n/a

LIBTAYO CEMIPLIMAB-RWIC x 09/28/2018 n/a

DARZALEX FASPRO DARATUMUMAB & HYALURONIDASE-FIHJ x 05/11/2020 n/a

DARZALEX DARATUMUMAB x 11/17/2015 n/a

VYXEOS DAUNORUBICIN and CYTARABINE x 08/11/2017 n/a

FIRMAGON DEGARELIX 04/01/2013 12/31/2014

DOCEFREZ DOCETAXEL x 04/01/2013 n/a

DOCETAXEL DOCETAXEL x 01/01/2024 n/a

IMFINZI DURVALUMAB x 05/01/2017 n/a

BEIZRAY DOCETAXEL x 07/01/2025 n/a

EMPLICITI ELOTUZUMAB x 11/30/2015 n/a

PADCEV ENFORTUMAB VEDOTIN-EJFV x 12/18/2019 n/a

HALAVEN ERIBULIN x 11/16/2010 n/a

AVGEMSI GEMCITABINE x 06/27/2025 n/a

INFUGEM GEMCITABINE HYDROCHLORIDE x 04/08/2019 n/a

GEMZAR GEMCITABINE 04/15/2009 12/31/2014

ZOLADEX GOSERELIN ACETATE x 01/01/2014 n/a

MYLOTARG GEMTUZUMAB OZOGAMICIN x 09/07/2017 n/a

POTELIGEO MOGAMULIZUMAB-KPKC x 08/17/2018 n/a

ONIVYDE IRINOTECAN LIPOSOME x 10/26/2015 n/a

CAMPTOSAR INJECTION, IRINOTECAN 05/15/2009 12/31/2014

IXEMPRA IXABEPILONE x 03/01/2026 n/a

GAMIFANT EMAPALUMAB-LZSG x 12/27/2018 n/a

INTRON A INTERFERON, ALFA-2B x SAD** 01/01/2006 12/31/2014

ALFERON N INTERFERON, ALFA-N3 x SAD** 01/01/2006 12/31/2014

ACTIMMUNE INTERFERON, GAMMA-1B x SAD** 01/01/2017 n/a

ELIGARD LEUPROLIDE ACETATE x 01/01/2005 n/a

LEUPROLIDE ACETATE x BOTH*** 01/01/2005 n/a

Leuprolide acetate LEUPROLIDE ACETATE x SAD** 01/01/2005 12/31/2014

ZEPZELCA LURBINECTEDIN x 06/19/2020 n/a

VANTAS HISTRELIN ACETTE x 11/10/2004 n/a

SUPPRELIN LA HISTRELIN ACETATE x 06/18/2007 n/a

SARCLISA ISATUXIMAB-IRFC x 03/09/2020 n/a

Example 1: Oncology drug, Yervoy ( ) requires prior auth listed below which the corresponding administration CPT code, , would be identified as a supportive

BESPONSA INOTUZUMAB OZOGAMICIN x 08/18/2017 n/a

EVOMELA MELPHALAN HCI 01/01/2017 n/a

PEPAXTO MELPHALAN FLUFENAMIDE x 03/01/2021 n/a

HEPZATO KIT MELPHALAN HYDROCHLORIDE x 08/14/2023 n/a

IMAAVY NIPOCALIMAB-AAHU x 04/29/2025 n/a New HCPCS, effective 01/01/2026

PACLITAXEL PACLITAXEL PROTEIN-BOUND x 07/01/2023 n/a

ARRANON NELARABINE x 03/01/2026 n/a

SYNRIBO OMACETAXINE MEPESUCCINATE x BOTH*** 11/12/2012 n/a

ELOXATIN OXALIPLATIN x 05/15/2009 06/14/2024

ABRAXANE PACLITAXEL x 05/15/2009 n/a

ONXOL PACLITAXEL 05/15/2009 12/31/2014

ELZONRIS TAGRAXOFUSP-ERZS x 12/21/2018 n/a

KEYTRUDA PEMBROLIZUMAB x 09/08/2014 n/a

JEMPERLI DOSTARLIMAB-GXLY x 04/22/2021 n/a

TIVDAK TISOTUMAB VEDOTIN-TFTV x 09/20/2021 n/a

KIMMTRAK TEBENTAFUSP-TEBN x 01/25/2022 n/a

UNLOXCYT COSIBELIMAB-IPDL x 12/13/2024 n/a

ZIIHERA ZANIDATAMAB-HRII x 11/21/2024 n/a

JELMYTO MITOMYCIN x 04/16/2020 n/a

ZUSDURI MITOMYCIN x 06/12/2025 n/a

LARTRUVO OLARATUMAB x 03/06/2017 n/a

COLUMVI GLOFITAMAB-GXBM x 06/15/2023 n/a

OPDIVO QVANTIG NIVOLUMAB AND HYALURONIDASE-NVHY x 12/27/2024 n/a

AXTLE PEMETREXED x 01/01/2025 n/a

PEMETREXED PEMETREXED x 04/01/2023 n/a

PORTRAZZA NECITUMUMAB x 12/14/2015 n/a

PEMETREXED PEMETREXED x 04/01/2023 n/a

PEMETREXED PEMETREXED x 04/01/2023 n/a

OPDUALAG NIVOLUMAB ELATLIMAB-RMBW x 03/18/2022 n/a

OPDIVO NIVOLUMAB x 12/23/2014 n/a

GAZYVA OBINUTUZUMAB x 11/01/2013 n/a

ARZERRA OFATUMUMAB x 06/01/2015 n/a

VECTIBIX PANITUMUMAB x 04/15/2009 n/a

PEMFEXY PEMETREXED x 10/01/2020 n/a

ALIMTA PEMETREXED x 05/15/2009 n/a

PERJETA PERTUZUMAB x 06/08/2012 n/a

FOLOTYN PRALATREXATE x 09/28/2009 n/a

CYRAMZA RAMUCIRUMAB x 04/28/2014 n/a

POLIVY POLATUZUMAB VEDOTIN-PIIQ x 06/10/2019 n/a

RITUXAN HYLECTA RITUXIMAB HYALURONIDASE x 06/22/2017 n/a

RITUXAN RITUXIMAB x 08/15/2006 n/a

LUMOXITI MOXETUMOMAB PASUDOTOX-TDFK x 10/16/2018 n/a

PEMETREXED PEMETREXED x 01/01/2023 n/a

PHESGO PERTUZUMAB, TRASTUZUMAB, and x 06/29/2020 n/a

TRODELVY SACITUZUMAB x 04/22/2020 n/a

ROMIDEPSIN ROMIDEPSIN, non-lyophilied x 03/13/2020 n/a

ISTODAX ROMIDEPSIN, lyophilied x 10/01/2021 n/a

EPKINLY EPCORITAMAB-BYSP x 05/19/2023 n/a

PEMETREXED PEMETREXED x 07/01/2023 n/a

PEMETREXED PEMETREXED x 07/01/2023 n/a

PEMRYDI RTU PEMETREXED x 01/01/2024 n/a

IMLYGIC TALIMOGENE LAHERPAREPVEC x 11/02/2015 n/a

EMRELIS TELISOTUZUMAB VEDOTIN-TLLV x 05/14/2025 n/a New HCPCS, effective 01/01/2026

TEVIMBRA TISLELIZUMAB x 03/13/2024 n/a

TORISEL TEMSIROLIMUS x 03/15/2014 n/a

FYARRO SIROLIMUS ALBUMIN-BOUND x 11/22/2021 n/a

VYVGART EFGARTIGIMOD ALFA-FCAB x 12/27/2021 n/a

RYSTIGGO ROZANOLIXIZUMAB-NOLI x 06/28/2023 n/a

VYVGART HYTRULO EFGARTIGIMOD ALFA-FCAB x 06/20/2023 n/a

TEPYLUTE THIOTEPA x 06/24/2024 n/a

ZYNYZ RETIFANLIMAB-DLWR x 03/22/2023 n/a

IMJUDO TREMELIMUMAB-ACTL x 10/21/2022 n/a

DANYELZA NAXITAMAB-CMKB x 11/25/2020 n/a

MONJUVI TAFASITAMAB-CXIX x 08/03/2020 n/a

LUNSUMIO MOSUNETUZUMAB-AXGB x 12/22/2022 n/a

YONDELIS TRABECTEDIN x 10/23/2015 n/a

MARGENZA MARGETUXIMAB-CMKB x 12/16/2021 n/a

KADCYLA ADO-TRASTUZUMAB x 02/22/2013 n/a

HERCEPTIN TRASTUZUMAB x 07/20/2009 n/a

HERCEPTIN HYLECTA TRASTUZUMAB HYALURONIDASE-OYSK x 04/08/2019 n/a

ENHERTU FAM-TRASTUZUMAB DERUXTECAN-NXKI x 12/20/2019 n/a

ZYNLONTA LONCASTUXIMAB TESIRINE-LPYL x 04/23/2021 n/a

RYZNEUTA EFBEMALENOGRASTIM ALFA-VUXW x 11/16/2023 n/a

VEOPOZ POZELIMAB-BBFG x 08/18/2023 n/a

TECVAYLI TECLISTAMAB-CQYV x 10/25/2022 n/a

TZIELD TEPLIZUMAB-MZWV x 11/17/2022 n/a

BIZENGRI ZENOCUTUZUMAB-ZBCO x 12/04/2025 n/a

FASLODEX FULVESTRANT 05/15/2009 12/31/2014

ZALTRAP ZIV-ALFILBERCEPT x 08/20/2012 n/a

AMTAGVI LIFILEUCEL 02/19/2024 n/a

TOFIDENCE MONOCLONAL ANTIBODY 10/01/2025 n/a

AVTOZMA TOCILIZUMAB-ANOH 10/01/2025 n/a

YESCARTA AXICABTAGENE CILOLEUCEL 10/18/2017 n/a

KYMRIAH TISAGENLECLEUCEL 08/31/2017 n/a

PROVENGE SIPULEUCEL-T AUTOLOGOUS CD54+ x 04/29/2010 n/a

LIPODOX DOXORUBICIN LIPOSOMAL x 04/01/2015 n/a

DOXIL DOXORUBICIN LIPOSOMAL x 04/01/2015 n/a

TECARTUS BREXUCABTAGENE AUTOLEUCEL 07/24/2020 n/a

BREYANZI CD4 LISOCABTAGENE MARALEUCEL 02/05/2021 n/a

ABECMA IDECABTAGENE VICLEUCEL 03/29/2021 n/a

CARVYKTI CILTACABTAGENE AUTOLEUCEL 03/01/2022 n/a

TECELRA AFAMITRESGENE AUTOLEUCEL 08/01/2024 n/a

AUCATZYL OBECABTAGENE AUTOLEUCEL 11/08/2024 n/a

AVONEX INTERFERON BETA-1A x SAD** 10/01/2011 n/a

REBIF INTERFERON BETA-1A x SAD** 10/01/2011 n/a

VENTAVIS ILOPROST INHALATION x SAD** 11/15/2009 n/a

* Unclassified Rx* UNCLASSIFIED DRUGS OR BOTH*** 01/01/2007 n/a

IMULDOSA IV USTEKINUMAB-SRLF IV x 10/10/2024 n/a

STEQEYMA IV USTEKINUMAB-STBA IV x 12/17/2024 n/a

YESINTEK IV USTEKINUMAB-KFCE IV x 11/29/2024 n/a

ZARXIO FILGRASTIM-SNDZ x BOTH*** 09/03/2015 n/a

INFLECTRA INFLIXIMAB-DYYB x 11/21/2016 n/a

RENFLEXIS INFLIXIMAB-ABDA x 07/25/2017 n/a

RETACRIT (ESRD) EPOETIN ALFA (ESRD) BOTH*** 06/18/2018 n/a

RETACRIT EPOETIN ALFA x BOTH*** 06/18/2018 n/a

MVASI BEVACIZUMAB-AWWB x 09/14/2017 n/a

FULPHILA PEGFILGRASTIM-JMDB x BOTH*** 07/09/2018 n/a

IXIFI INFLIXIMAB-QBTX x 01/01/2019 n/a HCPCS Termed 12/31/2025

NIVESTYM FILGRASTIM-AAFI x BOTH*** 09/24/2018 n/a

UDENYCA PEGFILGRASTIM-CBQV x BOTH*** 01/01/2019 n/a

ONTRUZANT TRASTUZUMAB-DTTB x 07/01/2019 n/a

HERZUMA TRASTUZUMAB-PKRB x 07/01/2019 n/a

OGIVRI TRASTUZUMAB-DKST x 12/01/2017 n/a

TRUXIMA RITUXIMAB-ABBS x 07/01/2019 n/a

TRAZIMERA TRAZIMERA x 10/01/2019 n/a

KANJINTI TRASTUZUMAB-ANNS x 07/22/2019 n/a

ZIRABEV ZIRABEV x 10/01/2019 n/a

RUXIENCE RITUXIMAB-PVVR x 07/23/2019 n/a

ZIEXTENZO PEGFILGRASTIM-BMEZ x BOTH*** 11/07/2019 n/a

AVSOLA INFLIXIMAB-AXXQ x 12/06/2019 n/a

NYVEPRIA PEGFILGRASTIM-APGF x BOTH*** 06/10/2020 n/a

RIABNI RITUXIMAB-ARRX x 12/17/2021 n/a

BYOOVIZ RANIBIZUMAB-NUNA x 09/20/2021 n/a

RELEUKO FILGRASTIM-AYOW x BOTH*** 02/25/2022 n/a

ALYMSYS BEVACIZUMAB-MALY x 04/13/2022 n/a

STIMUFEND PEGFILGRASTIM-FPGK x BOTH*** 09/01/2022 n/a

CIMERLI RANIBIZUMAB-EQRN x 08/02/2022 n/a

VEGZELMA BEVACIZUMAB-ADCD x 09/27/2022 n/a

FYLNETRA PEGFILGRASTIM-PBBK x BOTH*** 05/26/2022 n/a

TOFIDENCE TOCILIZUMAB-BAVI x 09/29/2023 n/a

TYRUKO NATALIZUMAB-SZTN x 08/24/2023 n/a

TYENNE IV TOCILIZUMAB-AAZG x 03/05/2024 n/a

JUBBONTI DENOSUMAB-BBDZ x 10/01/2024 n/a

WEZLANA SQ USTEKINUMAB-AUUB SQ x BOTH*** 10/31/2023 n/a

WEZLANA IV USTEKINUMAB-AUUB IV x 10/31/2023 n/a

HULIO ADALIMUMAB-FKJP x SAD** 07/01/2023 n/a

YUFLYMA ADALIMUMAB-AATY x SAD** 05/23/2023 n/a

SIMLANDI ADALIMUMAB-RYVK x SAD** 11/14/2024 n/a

CYLTEZO ADALIMUMAB-ADBM x SAD** 07/01/2023 n/a

IDACIO ADALIMUMAB x SAD** 12/14/2022 n/a

ABRILADA ADALIMUMAB-AFZB x SAD** 11/15/2019 n/a

HERCESSI TRASTUZUMAB-STRF x 04/25/2024 n/a

PAVBLU AFLIBERCEPT-AYYH x 08/23/2024 n/a

NYPOZI FILGRASTIM-TXID x BOTH*** 06/28/2024 n/a

ENZEEVU AFLIBERCEPT-ABZV x 08/09/2024 n/a

AHZANTIVE AFLIBERCEPT-MRBB x 06/28/2024 n/a

EPYSQLI ECULIZUMAB-AAGH x 07/19/2024 n/a

BKEMV ECULIZUMAB-AEEB x 05/28/2024 n/a

OPUVIZ AFLIBERCEPT-YSZY x 05/20/2024 n/a

OMLYCLO OMALIZUMAB-IGEC x 03/07/2025 n/a New HCPCS, effective 10/01/2025

YESAFILI AFLIBERCEPT-JBVF x 10/01/2025 n/a

AVTOZMA IV TOCILIZUMAB-ANOH IV x 01/30/2025 n/a New HCPCS, effective 10/01/2025

OSENVELT DENOSUMAB-BMWO x 02/28/2025 n/a New HCPCS, effective 10/01/2025

BOMYNTRA DENOSUMAB-BNHT x 03/25/2025 n/a New HCPCS, effective 10/01/2025

OSPOMYV DENOSUMAB-DSSB x 02/13/2025 n/a New HCPCS, effective 10/01/2025

JOBEVNE BEVACIZUMAB-NWGD x 04/09/2025 n/a New HCPCS, effective 01/01/2026

SUBLOCADE BUPRENORPHINE x 01/01/2018 n/a

SUBLOCADE BUPRENORPHINE x 01/01/2018 n/a

PYZCHIVA SQ USTEKINUMAB-TTWE SQ x BOTH*** 06/28/2024 n/a

PYZCHIVA IV USTEKINUMAB-TTWE IV x 06/28/2024 n/a

SELARSDI USTEKINUMAB-AEKN x BOTH*** 04/16/2024 n/a

OTULFI IV USTEKINUMAB-AAUZ IV x 09/27/2024 n/a

SPRAVATO ESKETAMINE 03/06/2019 n/a New HCPCS, effective 01/01/2026

GLEEVEC IMATINIB x SAD** 01/01/2012 n/a

MENOPUR MENOTROPINS INJECTION x SAD** 04/11/2005 n/a infertility benefit review

GONAL-F FOLLITROPIN ALFA x SAD** 10/01/1997 n/a infertility benefit review

FOLLISTIM AQ FOLLITROPIN BETA x SAD** 03/23/2004 n/a infertility benefit review

GANIRELIX GANIRELIX ACETATE x SAD** 05/01/2003 n/a infertility benefit review

PEGASYS PEGYLATED INTERFERON ALFA-2A x SAD** 01/01/2016 n/a

PEG INTRON PEGYLATED INTERFERON ALFA-2B x SAD** 01/01/2006 n/a

TESTOPEL TESTOSTERONE PELLETS x 06/15/2010 n/a New HCPCS, effective 01/01/2026

KORLYM MIFEPRISTONE x SAD** 03/23/2012 n/a

* UNLISTED GENERIC PRESCRIPTION DRUG, GENERIC NAME x SAD** 01/01/2000 n/a

* UNLISTED BRAND PRESCRIPTION DRUG, BRAND NAME x SAD** 01/01/2000 n/a