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.
Policy name | Policy number | Description | New or revised | Effective date | Notification date |
|---|---|---|---|---|---|
Camzyos, mavacamten | Dru720 | The concomitant use of Camzyos with disopyramide is considered investigational and therefore not covered | Revised | July 1, 2025 | April 1, 2025 |
CGRP Monoclonal Antibodies | Dru540 | The concomitant use of multiple CGRP agents (oral or injectable) is considered investigational and therefore not covered | Revised | July 1, 2025 | April 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 | July 1, 2025 | April 1, 2025 |
Medications for transthyretin-mediated amyloidosis | Dru733 |
| Revised | July 1, 2025 | April 1, 2025 |
Provider-Administered Specialty Drugs | Dru764 | Added the following products to the Provider-Administered Specialty Drug List:
| Revised | July 1, 2025 | April 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 | July 1, 2025 | April 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 | July 1, 2025 | April 1, 2025 |
Drugs for chronic inflammatory diseases | Dru444 | The preferred adalimumab (Humira) products will be certain biosimilars only. | Revised | January 1, 2026 | April 1, 2025 |