Medical Specialty Drug Policies

Precertification is required for designated new-to market specialty drugs. Precertification of the drug will be required on the market launch date of the drug. For details, please refer to Specialty Drugs Requiring Precertification.

Existing Policies

HMSA medical policies rely on the use of evidence-based medicine, which typically comes from peer-reviewed literature. Physicians submitting comments should include citation source material to support their positions. Inclusion of this material will help HMSA's pharmacy benefit manager and HMSA's medical directors evaluate the comment or proposed change.

#

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
1% sodium hyaluronate (Medicare Advantage)		03/13/2026	Medicare Advantage Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (MA)

A

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Abecma (idecabtagene vicleucel)	Please contact HMSA at 808-948-6464, option #4, for drug review
1. Abrilada (adalimumab-afzb)(Autoimmune Preferred Drug Program) (Commercial)		01/01/2026		Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Abrilada (adalimumab-afzb) (Commercial)		05/25/2025	Commercial Fax Form	Humira (adalimumab) Effective 12/1/2023	ARCHIVED - Adalimumab (Humira)
Abrilada (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QUEST)
1. Actemra (tocilizumab) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Actemra Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first.	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Actemra (tocilizumab) (Commercial)		04/01/2026	Commercial Fax Form QUEST Fax Form	Actemra-Avtozma-Tofidence-Tyenne	ARCHIVED - Actemra (COMM-QUEST) ARCHIVED - Actemra
Actemra (tocilizumab) (QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Actemra-Avtozma-Tofidence-Tyenne	ARCHIVED - Actemra (COMM-QUEST) ARCHIVED - Actemra
Actemra (tocilizumab) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form		ARCHIVED - Actemra (MA)
Actimmune (interferon gamma-1b)		06/12/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Adakveo (crizanlizumab-tmca)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Adalimumab Preferred Drug Program + Drug Specific Criteria (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QUEST)
1. adalimumab-aacf (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for adalimumab-aacf Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first.	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. adalimumab-aacf (Commercial)		05/25/2025		Humira (adalimumab) Effective 7/1/2024	ARCHIVED - Humira
Adalimumab-aacf (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QUEST)
1. adalimumab-aaty (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for adalimumab-aaty Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first.	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. adalimumab-aaty (Commercial)		05/25/2025		Humira (adalimumab) Effective 7/1/2024	ARCHIVED - Adalimumab (Humira)
Adalimumab-aaty (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QUEST)
1. adalimumab-adaz (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for adalimumab-adaz Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first.	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. adalimumab-adaz (Commercial)		05/25/2025	Commercial Fax Form	Humira (adalimumab) Effective 7/1/2024	ARCHIVED - Adalimumab (Humira)
adalimumab-adaz (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QUEST)
1. adalimumab-adbm (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for adalimumab-adbm Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first.	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. adalimumab-adbm (Commercial)		05/25/2025		Humira (adalimumab) Effective 7/1/2024	ARCHIVED - Adalimumab (Humira)
adalimumab-adbm (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QUEST)
adalimumab-bwwd (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QUEST)
1. adalimumab-fkjp (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for adalimumab-fkjp Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first.	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. adalimumab-fkjp (Commercial)		05/25/2025		Humira (adalimumab) Effective 7/1/2024	ARCHIVED - Adalimumab (Humira)
adalimumab-fkjp (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QUEST)
1. adalimumab-ryvk (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for adalimumab-ryvk Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first.	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. adalimumab-ryvk (Commercial)		05/25/2025	Commercial Fax Form	Humira (adalimumab) Effective 7/1/2024	ARCHIVED - Adalimumab (Humira)
adalimumab-ryvk (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QUEST)
1. Adbry (tralokinumab-idrm) (Atopic Dermatitis Preferred Program) (Commercial)		01/01/2026		Atopic Dermatitis Preferred Program Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Atopic Dermatitis (Commercial)
2. Adbry (tralokinumab-idrm) (Commercial)		07/01/2026	Commercial Fax Form	Effective 7/1/23: Drug specific policy Specialty Drugs Requiring Precertification (SDRP) removed eff 7/1/2023; added eff 4/1/2022	ARCHIVED - Adbry ARCHIVED - SDRP
Adbry (QUEST)		07/01/2026	QUEST Fax Form		ARCHIVED - Adbry (QUEST)
Adstiladrin (nadofaragene firadenovec-vncg)	Please contact HMSA at 808-948-6464, option #4, for drug review
Aduhelm (aducanumab-avwa)	Please contact HMSA at 808-948-6464, option #4, for questions
Advate [Factor VIII (recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Adynovate [Factor VIII (recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Adzynma (ADAMTS13, recombinant-krhn)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Effective 12/01/2023	ARCHIVED - SDRP
Afstyla [Factor VIII (recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Aimovig (erenumab-aooe)		06/12/2026	Fax Form	Specialty Drugs Requiring Precertification (SDRP) Drug is not covered under Part B	ARCHIVED - SDRP
Ajovy (fremanezumab-vfrm)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Alhemo [Tissue Factor Pathway Inhibitor (concizumab-mtci)]	Please contact HMSA at 808-948-6464, option #4, for drug review.
Alimta (Pemetrexed)	Alimta discontinued as of 04/01/2026			Global Oncology	ARCHIVED - Global Oncology
Aliqopa (copanlisib)				Aliqopa was removed from the market. Global Oncology	ARCHIVED - Global Oncology
Alphanate [Factor VIII (plasma derived)]	Please contact HMSA at 808-948-6464, option #4, for drug review
AlphaNine SD [Factor IX (plasma derived)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Alprolix [Factor IX (Recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Altuviiio [Factor VIII (Recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Alyglo (Commercial and QUEST)		07/25/2025	Commercial Fax Form QUEST Fax Form	Intravenous Immune Globulin (IVIG) - Comm-QUEST	ARCHIVED - IVIG (Comm-QUEST)
Alyglo (Medicare Advantage)		06/26/2026	Medicare Advantage Fax Form	Intravenous Immune Globulin (IVIG) - MA	ARCHIVED - IVIG (MA)
1. Alymsys (bevacizumab-maly) (Bevacizumab Preferred Drug Program policy Commercial)		01/01/2026		Bevacizumab Products - Preferred Drug Program Commercial Effective 1/1/2024	ARCHIVED - Bevacizumab Products (Commercial)
2. Alymsys (bevacizumab-maly) (Commercial)		06/12/2026	Commercial Fax Form	Global Oncology Effective 10/11/2023	ARCHIVED - Global Oncology
1. Alymsys (bevacizumab-maly) (Bevacizumab Preferred Drug Program policy Medicare Advantage)		01/01/2026		Bevacizumab Products - Preferred Drug Program MA Effective 1/1/2024	ARCHIVED - Bevacizumab Products (MA)
2. Alymsys (bevacizumab-maly) (Medicare Advantage)		06/12/2026	Medicare Advantage Fax Form	Global Oncology Effective 10/11/2023	ARCHIVED - Global Oncology
1. Alymsys (bevacizumab-maly) (Bevacizumab Preferred Drug Program policy QUEST)		01/01/2026		Bevacizumab Products - Preferred Drug Program QUEST Effective 1/1/2025	ARCHIVED - Bevacizumab Products (QUEST)
2. Alymsys (bevacizumab-maly) (QUEST)		06/12/2026	QUEST Fax Form	Global Oncology Effective 10/11/2023	ARCHIVED - Global Oncology
1. Amjevita (adalimumab-atto) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026		Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Amjevita (adalimumab-atto) (Commercial)		05/25/2025	Commercial Fax Form	Humira (adalimumab) Effective 12/1/2023	ARCHIVED - Adalimumab (Humira)
Amjevita (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QUEST)
Amondys 45 (casimersen)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Amtagvi (lifileucel)	Please contact HMSA at 808-948-6464, option #4, for drug review
Amvuttra (vutrisiran)	Effective 02/15/2024: Please contact HMSA at 808-948-6464, option #4, for drug review			Effective 2/15/2024 PA review for Amvuttra is moved from CVS to HMSA review
Andembry (garadacimab-gxii)		06/12/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Added effective 07/01/2025	ARCHIVED - SDRP
Anktiva (nogapendekin alfa inbakicept-pmln)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Effective 5/17/2024	ARCHIVED - Global Oncology
Aphexda (motixafortide)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Effective 10/01/2023	ARCHIVED - SDRP
Apligraf (graftskin)	Please contact HMSA at 808-948-6464, option #4, for drug review
Aranesp				No PA required as of 11/23/2015
Arcalyst (rilonacept) (Commercial and QUEST)	No PA required for Medicare Advantage effective 1/1/2024	04/01/2026	Commercial Fax Form QUEST Fax Form		ARCHIVED - Arcalyst
arsenic trioxide (generic)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Asceniv (immune globulin intravenous, human – slra) (Commerical & QUEST)		07/25/2025	Commercial Fax Form QUEST Fax Form	Intravenous Immune Globulin (IVIG) - Comm-QUEST	ARCHIVED - IVIG (Comm-QUEST)
Asceniv (immune globulin intravenous, human – slra) (Medicare Advantage)		06/26/2026	Medicare Advantage Fax Form	Intravenous Immune Globulin (IVIG) - MA	ARCHIVED - IVIG (MA)
Asparlas (calaspargase pegol-mknl)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Atopic Dermatitis Preferred Program (Commercial)		01/01/2026		Atopic Dermatitis Preferred Program	ARCHIVED - Atopic Dermatitis (Commercial)
Autoimmune Preferred Drug Program (Commercial)		01/01/2026			ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
1. Avastin (bevacizumab) (Bevacizumab Preferred Drug Program policy Commercial)		01/01/2026	Commercial Fax Form	Bevacizumab Products - Preferred Drug Program Commercial Effective 1/1/2024	ARCHIVED - Bevacizumab Products (Commercial)
2. Avastin (bevacizumab) (Commercial)		06/12/2026		Global Oncology	ARCHIVED - Global Oncology
1. Avastin (bevacizumab) (Bevacizumab Preferred Drug Program policy Medicare Advantage)		01/01/2026	Medicare Advantage Fax Form	Bevacizumab Products - Preferred Drug Program MA Effective 1/1/2024	ARCHIVED - Bevacizumab Products (MA)
2. Avastin (bevacizumab) (Medicare Advantage)		06/12/2026		Global Oncology	ARCHIVED - Global Oncology
1. Avastin (bevacizumab) (Bevacizumab Preferred Drug Program policy QUEST)		01/01/2026		Bevacizumab Products - Preferred Drug Program QUEST Effective 1/1/2025	ARCHIVED - Bevacizumab Products (QUEST)
2. Avastin (bevacizumab) (QUEST)		06/12/2026	QUEST Fax Form	Global Oncology	ARCHIVED - Global Oncology
Avastin (bevacizumab) (Retinal Disorders) (Commercial and QUEST) (non-oncology)	No PA required				ARCHIVED - Retinal Disorders Preferred Drug Program (Commercial)
Avastin (bevacizumab) (Retinal Disorders) (Medicare Advantage) (non-oncology)	No PA required as of 01/01/2024			Retinal Disorders Preferred Drug Program Effective 6/1/2021	ARCHIVED - Retinal Disorders Preferred Drug Program (MA)
Avlayah (tividenofusp alfa-eknm)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Effective 10/01/2023	ARCHIVED - SDRP
Avonex (interferon beta-1a) (Commercial)	No PA required as of 7/1/2022	11/21/2025		Multiple Sclerosis (MS) - Interferons Preferred Drug Program	ARCHIVED - Multiple Sclerosis (MS) – Preferred Drug Program
1. Avsola (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	See below for Avsola Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first.	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Avsola (infliximab-axxq) (Commercial)		04/01/2026	Commercial Fax Form	Infliximab-Avsola-Inflectra-Remicade-Renflexis-Zymfentra	ARCHIVED - Infliximab (Comm-QUEST) ARCHIVED - Infliximab
Avsola (infliximab-axxq) (QUEST)		07/01/2026	QUEST Fax Form	Infliximab-Avsola-Inflectra-Renflexis-Zymfentra (QUEST)	ARCHIVED - Infliximab (QUEST)
Avsola (infliximab-axxq) (Medicare Advantage)		12/19/2025	Medicare Advantage Fax Form	Infliximab-Avsola-Inflectra-Remicade-Renflexis MA	ARCHIVED - Infliximab (MA)
Avtozma (tocilizumab-anoh) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Actemra-Avtozma-Tofidence-Tyenne	ARCHIVED - Actemra (COMM-QUEST)
Avtozma (tocilizumab-anoh) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Actemra-Avtozma-Tofidence-Tyenne	ARCHIVED - Actemra (MA)
Azedra	No PA required			No PA required as of 3/1/2019

B

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Bavencio (avelumab)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Beizray (docetaxel)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Added eff 11/18/2025	ARCHIVED - Global Oncology
Benefix [Factor IX (recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Benlysta (belimumab) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form		ARCHIVED - Benlysta (Comm-QUEST) ARCHIVED - Benlysta
Benlysta (belimumab) (Medicare Advantage)		06/27/2025	Medicare Advantage Fax Form		ARCHIVED - Benlysta (MA)
1. Beovu (brolucizumab-dbll) (Medicare Advantage)	No PA required as of 01/01/2024 for Retinal Disorders			Retinal Disorders Preferred Drug Program	ARCHIVED - Retinal Disorders Preferred Drug Program (MA)
2. Beovu (brolucizumab-dbll)	No PA required as of 01/11/2024			Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
1. Berinert (C1 esterase inhibitor [human]) (Hereditary Angioedema Preferred Drug Program) (Commercial)		11/21/2025	Refer below for Berinert Fax Forms	Hereditary Angioedema Preferred Drug Program	ARCHIVED - Hereditary Angioedema Preferred Drug Program
2. Berinert (C1 esterase inhibitor [human]) (Commercial and QUEST)		01/19/2026	Commercial Fax Form QUEST Fax Form		ARCHIVED - Berinert (Comm-QUEST) ARCHIVED - Berinert
Berinert (C1 esterase inhibitor [human]) (Medicare Advantage)		12/19/2025	Medicare Advantage Fax Form		ARCHIVED - Berinert (MA)
Besponsa (inotuzumab ozogamicin)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Besremi ropeginterferon alfa-2b-njft)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Betaseron (interferon beta-1b) (Commercial)	No PA required	11/21/2025		Multiple Sclerosis (MS) - Interferons Preferred Drug Program	ARCHIVED - Multiple Sclerosis (MS) – Preferred Drug Program
Bevacizumab Preferred Drug Program (Commercial)		01/01/2026		Bevacizumab Products - Preferred Drug Program Commercial Effective 1/1/2024	ARCHIVED - Bevacizumab Products (Commercial)
Bevacizumab Preferred Drug Program (Medicare Advantage)		01/01/2026		Bevacizumab Products - Preferred Drug Program MA Effective 1/1/2024	ARCHIVED - Bevacizumab Products (MA)
Bevacizumab Preferred Drug Program (QUEST)		01/01/2026		Bevacizumab Products - Preferred Drug Program MA Effective 1/1/2025	ARCHIVED - Bevacizumab Products (QUEST)
Bildyos (denosumab-nxxp) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Prolia and Biosimilars (Commercial and QUEST)	ARCHIVED - Prolia (Comm-QUEST)
Bildyos (denosumab-nxxp) (Medicare Advantage)	60-day provider notice 08/01/2026-09/30/2026, in effect 10/01/2026	06/27/2025	Medicare Advantage Fax Form	Prolia and Biosimilars (Medicare Advantage) Added effective 6/27/2025	ARCHIVED - Prolia (MA)
1. Bimzelx (bimekizumab-bkzx) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Bimzelx Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Bimzelx (bimekizumab-bkzx) (Commercial and QUEST)		06/26/2026	Commercial Fax Form QUEST Fax Form	Drug-specific policy in effect 2/1/2026 Specialty Drugs Requiring Precertification (SDRP) Removed effective 2/1/2026	ARCHIVED - Bimzelx ARCHIVED - SDRP
Bimzelx (bimekizumab-bkzx) (Medicare Advantage)		06/12/2026	Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Bivigam (human immunoglobulin) (Commercial & QUEST)		07/25/2025	Commercial Fax Form QUEST Fax Form	Intravenous Immune Globulin (IVIG)	ARCHIVED - IVIG (Comm-QUEST)
Bivigam (human immunoglobulin) (Medicare Advantage)		06/26/2026	Medicare Advantage Fax Form	Intravenous Immune Globulin (IVIG) - MA	ARCHIVED - IVIG (MA)
Bizengri (zenocutuzumab-zbco)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Bkemv (eculizumab-aeeb) (Commercial and QUEST)		12/19/2025		Soliris	ARCHIVED - Soliris (Comm-QUEST)
Bkemv (eculizumab-aeeb) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Soliris-Bkemy-Epysqli	ARCHIVED - Soliris (MA)
Blenrep (belantamab mafodotin-blmf)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Bomyntra (denosumab-bnht) (Commercial and QUEST)		06/27/2025	Commercial Fax Form QUEST Fax Form	Xgeva and Biosimilars (Commercial and QUEST) Added eff 6/27/2025	ARCHIVED - Xgeva (Comm-QUEST)
Bomyntra (denosumab-bnht) (Medicare Advantage)		06/27/2025	Medicare Advantage Fax Form	Xgeva and Biosimilars (Medicare Advantage) Added eff 6/27/2025	ARCHIVED - Xgeva (MA)
Bonsity (teriparatide)		06/27/2025	Fax Form	Forteo (teriparatide) Effective 4/1/2023	ARCHIVED - Forteo
bortezomib (generic)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Boruzu (bortezomib)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Bosaya (denosumab-kyqq) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Prolia and Biosimilars (Commercial and QUEST)	ARCHIVED - Prolia (Comm-QUEST)
Bosaya (denosumab-kyqq) (Medicare Advantage)	60-day provider notice 08/01/2026-09/30/2026, in effect 10/01/2026	06/27/2025	Medicare Advantage Fax Form	Prolia and Biosimilars (Medicare Advantage) Added effective 6/27/2025	ARCHIVED - Prolia (MA)
Botox (Botulinum Toxins)		04/01/2026	Fax Form QUEST Fax Form Medicare Advantage Fax Form	Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY)	ARCHIVED - Botulinum Toxins
1. Botox (Botulinum Toxins Preferred Drug Program) (Medicare Advantage)		11/21/2025	Refer below for Botox Fax Forms	Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY) Preferred Drug Program	ARCHIVED - Botulinum Toxins Preferred Drug Program MA
2. Botox (onabotulinumtoxinA)		04/01/2026	Fax Form QUEST Fax Form Medicare Advantage Fax Form	Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY)	ARCHIVED - Botulinum Toxins
Botulinum Toxins Preferred Drug Program (Medicare Advantage)		11/21/2025	Refer below for Botulinum Toxins Fax Forms	Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY) Preferred Drug Program	ARCHIVED - Botulinum Toxins Preferred Drug Program MA
Botulinum Toxins		04/01/2026		Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY)	ARCHIVED - Botulinum Toxins
Breyanzi (lisocabtagene maraleucel)	Please contact HMSA at 808-948-6464, option #4, for drug review
Brineura (cerliponase alfa)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Briumvi (ublituximab-xiiy)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Added effective 3/1/2023	ARCHIVED - SDRP
Brixadi (buprenorphine)		06/12/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Added effective 9/1/2023	ARCHIVED - SDRP
Byooviz (ranibizumab-nuna) (Medicare Advantage)	No PA required as of 01/01/2024			Retinal Disorders Preferred Drug Program	ARCHIVED - Retinal Disorders Preferred Drug Program (MA)

C

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Cablivi Kit (caplacizumab-yhdp)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Camcevi (leuprolide mesylate)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Carimune NF (human immunoglobulin) (Commercial & QUEST)				Carimune NF (Commercial and QUEST) inactive and removed as of 09/01/2022. Intravenous Immune Globulin (IVIG)	ARCHIVED - IVIG Refer to archived policies eff through 8/31/2022
Carimune NF (human immunoglobulin) (Medicare Advantage)				Carimune NF (Medicare Advantage) inactive and removed as of 09/01/2022. Intravenous Immune Globulin (IVIG) - MA	ARCHIVED - IVIG (MA) Refer to archived policies eff through 8/31/2022
Carvykti (ciltacabtagene autoleucel)	Please contact HMSA at 808-948-6464, option #4, for drug review
Casgevy (exagamglogene autotemcel)	Please contact HMSA at 808-948-6464, option #4, for drug review
Cerezyme (imiglucerase) (Commercial and QUEST)		05/23/2025	Fax Form		ARCHIVED - Cerezyme (Commerical-QUEST) ARCHIVED - Cerezyme
Cerezyme (imiglucerase) (Medicare Advantage)		05/23/2025	Medicare Advantage Fax Form		ARCHIVED - Cerezyme (MA)
1. Cimzia (certolizumab pegol) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Cimzia Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Cimzia (certolizumab pegol) (Commercial and QUEST)		08/01/2025	Commercial Fax Form QUEST Fax Form	Specific drug criteria for Cimzia	ARCHIVED - Cimzia (Comm-QUEST) ARCHIVED - Cimzia
Cimzia (certolizumab pegol) (Medicare Advantage)		03/27/2026	Medicare Advantage Fax Form		ARCHIVED - Cimzia (MA)
Cinqair (reslizumab)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Cinryze (C1 esterase inhibitor) (Commercial and QUEST)		01/19/2026	Commercial Fax Form QUEST Fax Form		ARCHIVED - Cinryze (Comm-QUEST) ARCHIVED - Cinryze
Cinryze (C1 esterase inhibitor) (Medicare Advantage)		01/19/2026	Medicare Advantage Fax Form		ARCHIVED - Cinryze (MA)
Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program (Commercial)		01/01/2026		Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program (Commercial)	ARCHIVED - CFS Long Acting Preferred Drug Program
Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program (Medicare Advantage)		01/01/2026		Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program (MA)	ARCHIVED - CFS Long Acting Preferred Drug Program (MA)
Colony Stimulating Factors (CSF) – Short Acting Preferred Drug Program (Commercial and QUEST)		11/21/2025		Colony Stimulating Factors (CSF) – Short Acting Preferred Drug Program	ARCHIVED - CFS Short Acting Preferred Drug Program
Colony Stimulating Factors (CSF) – Short Acting Preferred Drug Program (Medicare Advantage)		11/21/2025		CSF–Short Acting Preferred Drug Program MA	ARCHIVED - CSF Short Acting (Preferred Drug Program) (MA)
Columvi (glofitamab-gxbm)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Eff 7/1/2023	ARCHIVED - SDRP
Conexxence (denosumab-bnht) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Prolia and Biosimilars (Commercial and QUEST)	ARCHIVED - Prolia (Comm-QUEST)
Conexxence (denosumab-bnht) (Medicare Advantage)	60-day provider notice 08/01/2026-09/30/2026, in effect 10/01/2026	06/27/2025	Medicare Advantage Fax Form	Prolia and Biosimilars (Medicare Advantage) Added eff 6/27/2025	ARCHIVED - Prolia (MA)
Cosela (trilaciclib)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
1. Cosentyx (secukinumab) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Cosentyx Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Cosentyx (secukinumab) (Commercial and QUEST)		10/01/2025	Commercial Fax Form QUEST Fax Form	Specific drug criteria for Cosentyx eff 10/1/2020	ARCHIVED - Cosentyx (Comm-QUEST)
Criteria Exception (Commercial and QUEST)		01/01/2026			ARCHIVED - Criteria Exception (Comm-QUEST)
Crysvita (burosumab-twza)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Cutaquig (Immune Globulin Subcutaneous [Human] – hipp) (Commercial and QUEST)		10/01/2025	Commercial Fax Form QUEST Fax Form	Subcutaneous Immunoglobulin (SCIG)	ARCHIVED - SCIG (Comm-QUEST)
Cutaquig (Immune Globulin Subcutaneous [Human] – hipp) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Subcutaneous Immunoglobulin (SCIG)	ARCHIVED SCIG (MA)
Cuvitru (Immune Globulin Subcutaneous [Human], 20% Solution) (Commercial and QUEST)		10/01/2025	Commercial Fax Form QUEST Fax Form	Subcutaneous Immunoglobulin (SCIG)	ARCHIVED - SCIG (Comm-QUEST)
Cuvitru (Immune Globulin Subcutaneous [Human], 20% Solution) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Subcutaneous Immunoglobulin (SCIG)	ARCHIVED - SCIG (MA)
1. Cyltezo (adalimumab-adbm) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026		Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Cyltezo (adalimumab-adbm) (Commercial)		05/25/2025	Commercial Fax Form	Humira (adalimumab) Effective 12/1/2023	ARCHIVED - Adalimumab (Humira)
Cyltezo (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QUEST)
Cyramza (ramucirumab)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology

D

Policy Name	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Danyelza (naxitamab-gqgk)	06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology (eff 3/1/2021)	ARCHIVED - Global Oncology
Darzalex (daratumumab)	06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Darzalex Faspro (daratumumab)	06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Datroway (datopotamab deruxtecan-dlnk)	06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Dawnzera (donidalorsen)	06/12/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Added effective: 09/12/2025	ARCHIVED - SDRP
Daxxify (daxibotulinumtoxinA-lanm)	04/01/2026	Fax Form QUEST Fax Form Medicare Advantage Fax Form	Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY) Effective 1/1/2025 Specialty Drugs Requiring Precertification (SDRP) Effective 1/1/25: Removed from SDRP policy	ARCHIVED - Botulinum Toxins ARCHIVED - SDRP
1. Daxxify (daxibotulinumtoxinA-lanm) (Botulinum Toxins Preferred Drug Program) (Medicare Advantage)	11/21/2025		Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY) Preferred Drug Program	ARCHIVED - Botulinum Toxins Preferred Drug Program MA
2. Daxxify (daxibotulinumtoxinA-lanm)	04/01/2026		Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY) Effective 1/1/2025	ARCHIVED - Botulinum Toxins
Decnupaz (pivekimab sunrine-pvzy)	06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Added effective 6/12/2026	ARCHIVED - Global Oncology
1. Dupixent (dupilumab) (Atopic Dermatitis Preferred Program) (Commercial)	01/01/2026		Atopic Dermatitis Preferred Program Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Atopic Dermatitis (Commercial)
2. Dupixent (dupilumab) (Commercial)	07/01/2026	Commercial Fax Form		ARCHIVED - Dupixent
Dupixent (dupilumab) (QUEST)	07/01/2026	QUEST Fax Form		ARCHIVED - Dupixent (QUEST)
1. Durolane (Hyaluronates Preferred Drug Program) (Commercial and QUEST)	01/01/2026	See below for Durolane Commercial Fax Form	Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (Commercial)
2. Durolane (hyaluronic acid) (Commercial and QUEST)	06/26/2026	Commercial Fax Form QUEST Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QI) ARCHIVED - Hyaluronates (drug specific)
1. Durolane (Hyaluronates Preferred Drug Program) (Medicare Advantage)	01/01/2026	See below for Durolane Medicare Advantage Fax Form	Hyaluronates Preferred Drug Program MA	ARCHIVED - Hyaluronates Preferred Drug Program (MA)
2. Durolane (hyaluronic acid) (Medicare Advantage)	03/13/2026	Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)
Dysport (abobotulinumtoxinA)	04/01/2026	Fax Form QUEST Fax Form Medicare Advantage Fax Form	Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY)	ARCHIVED - Botulinum Toxins
1. Dysport (Botulinum Toxins Preferred Drug Program) (Medicare Advantage)	11/21/2025	Refer below for Dysport Fax Forms	Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY) Preferred Drug Program	ARCHIVED - Botulinum Toxins Preferred Drug Program MA
2. Dysport (abobotulinumtoxinA)	04/01/2026	Fax Form QUEST Fax Form Medicare Advantage Fax Form	Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY)	ARCHIVED - Botulinum Toxins

E

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
1. Ebglyss (lebrikizumab-lbkz) (Atopic Dermatitis Preferred Program) (Commercial)		01/01/2026		Atopic Dermatitis Preferred Program Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Atopic Dermatitis (Commercial)
2. Ebglyss (lebrikizumab-lbkz) (Commercial)		07/01/2026	Commercial Fax Form	Effective 7/1/2026, HMSA split out Commercial and QUEST. Drug-specific policy effective 01/01/2026 Effective 01/01/2026: Removed from SDRP policy	ARCHIVED - Ebglyss ARCHIVED - SDRP
Ebglyss (lebrikizumab-lbkz) (QUEST)		07/01/2026	QUEST Fax Form		ARCHIVED - Ebglyss (QUEST)
edaravone (generic)		06/12/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Effective: 12/16/2024	ARCHIVED - SDRP
Egrifta (tesamorelin acetate)		06/12/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Added effective: 08/01/2025	ARCHIVED - SDRP
Elahere (mirvetuximab soravtansine-gynx)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Effective 12/02/2022	ARCHIVED - Global Oncology
Elelyso (taliglucerase) (Commercial and QUEST)		03/01/2026	Commercial Fax Form QUEST Fax Form		ARCHIVED - Elelyso (Comm-QUEST) ARCHIVED - Elelyso
Elelyso (taliglucerase) (Medicare Advantage)		09/26/2025	Medicare Advantage Fax Form		ARCHIVED - Elelyso (MA)
Elevidys Kit (delandistrogene moxeparvovec-rokl)	Please contact HMSA at 808-948-6464, option #4, for drug review
Elfabrio (pegunigalsidase alfa-lwxj)		06/12/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Effective 6/01/2023	ARCHIVED - SDRP
Eligard (leuprolide acetate)	No PA required for Medicare Advantage	06/12/2026	Fax Form	Global Oncology	ARCHIVED - Global Oncology
Eloctate [Factor VIII (Recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Elrexfio (elranatamab-bcmm)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Added effective 9/5/2023	ARCHIVED - Global Oncology
Elzonris (tagraxofusp-erzs)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Emgality (galcanezumab-gnlm)		06/12/2026	Commercial Fax Form QUEST Fax Form	Specialty Drugs Requiring Precertification (SDRP) Drug is not covered under Part B	ARCHIVED - SDRP
Empaveli (pegcetacoplan)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Empliciti (elotuzumab)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Emrelis (telisotuzumab vedotin-tllv)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Added effective 7/10/2025	ARCHIVED - Global Oncology
1. Enbrel (etanercept) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Enbrel Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Enbrel (etanercept) (Commercial and QUEST)		08/01/2025	Fax Form	Specific drug criteria for Enbrel	ARCHIVED - Enbrel (Comm-QUEST)
Enhertu (fam-trastuzumab deruxtecan-nxki)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Enjaymo (sutimlimab-jome)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) eff 4/1/2022	ARCHIVED - SDRP
Enoby (denosumab-qbde) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Prolia and Biosimilars (Commercial and QUEST)	ARCHIVED - Prolia (Comm-QUEST)
Enoby (denosumab-qbde) (Medicare Advantage)	60-day provider notice 08/01/2026-09/30/2026, in effect 10/01/2026	06/27/2025	Medicare Advantage Fax Form	Prolia and Biosimilars (Medicare Advantage) Added effective 6/27/2025	ARCHIVED - Prolia (MA)
Enspryng (satralizumab-mwge)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
1. Entyvio (vedolizumab) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	See below for Entyvio fax form	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Entyvio (vedolizumab) (Commercial and QUEST)		08/01/2025	Commercial Fax Form QUEST Fax Form	Specific drug criteria for Entyvio	ARCHIVED - Entyvio (Comm-QI) ARCHIVED - Entyviio (Comm-QI-MA)
Entyvio (vedolizumab) (Medicare Advantage)		04/25/2025	Medicare Advantage Fax Form		ARCHIVED - Entyvio (MA)
Epkinly (epcoritamab-bysp)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Added effective 7/21/2023	ARCHIVED - Global Oncology
Epogen				No PA required as of 11/23/15
epoprostenol (generic) (Commercial and QUEST)		06/01/2026	Fax Form	Flolan; Veletri; epoprostenol (generic)	ARCHIVED - Flolan-Veletri-epoprostenol (Comm-QI) ARCHIVED - Flolan-Veletri
epoprostenol (generic) (Medicare Advantage)		12/19/2025	Medicare Advantage Fax Form	Flolan; Veletri; epoprostenol (generic) MA	ARCHIVED - Flolan-Veletri-epoprostenol (MA)
Epysqli (eculizumab-aagh) (Commercial and QUEST)		12/19/2025		Soliris	ARCHIVED - Soliris (Comm-QUEST)
Epysqli (eculizumab-aagh) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Soliris-Bkemy-Epysqli	ARCHIVED - Soliris (MA)
Erbitux (cetuximab)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Erythropoiesis Stimulating Agents (ESAs)				No PA required as of 11/23/15
Esperoct [Factor VIII (recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
1. Euflexxa® (Hyaluronates Preferred Drug Program) (Commercial and QUEST)		01/01/2026	See below for Euflexxa Commercial Fax Form	Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (Commercial)
2. Euflexxa® (1% sodium hyaluronate) (Commercial and QUEST)		06/26/2026	Commercial Fax Form QUEST Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QI) ARCHIVED - Hyaluronates (drug specific)
1. Euflexxa (Hyaluronates Preferred Drug Program) (Medicare Advantage)		01/01/2026	See below for Euflexxa Medicare Advantage Fax Form	Hyaluronates Preferred Drug Program MA	ARCHIVED - Hyaluronates Preferred Drug Program (MA)
2. Euflexxa® (1% sodium hyaluronate) (Medicare Advantage)		03/13/2026	Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)
Evdi (trabectedin)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Added effective 6/12/2026	ARCHIVED - Global Oncology
Evenity (romosozumab-aqqg) (Commercial and QUEST)		12/19/2025	Commerical Fax Form QUEST Fax Form	Effective 4/1/23: Drug specific policy Specialty Drugs Requiring Precertification (SDRP) Effective 4/1/23: Removed from SDRP policy.	ARCHIVED - Evenity (Comm/QI) ARCHIVED - Evenity Refer to policies eff 4/1/2023 and later ARCHIVED - SDRP
Evenity (romosozumab-aqqg) (Medicare Advantage)		06/27/2025	Medicare Advantage Fax Form		ARCHIVED - Evenity (MA)
Evkeeza (evinacumab-dgnb)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Exdensur (depemokimab-ulaa)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Exondys 51 (eteplirsen)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Extavia (interferon beta-1b) (Multiple Sclerosis Preferred Program) (Commercial)		11/21/2025	Commercial Fax Form	Multiple Sclerosis (MS) - Interferons Preferred Drug Program	ARCHIVED - Multiple Sclerosis (MS) – Preferred Drug Program
Eylea (aflibercept) (Commercial and QUEST)	No PA required
Eylea (aflibercept) Medicare Advantage)	No PA required as of 01/01/2024			Retinal Disorders Preferred Drug Program	ARCHIVED - Retinal Disorders Preferred Drug Program (MA)

F

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Fasenra (benralizumab)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Favlyxa (fluorouracil)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Added effective 4/14/2026	ARCHIVED - Global Oncology
Feiba [Anti-inhibitor coagulant complex]	Please contact HMSA at 808-948-6464, option #4, for drug review
Fensolvi (leuprolide acetate) (Non-oncology) (Commercial and QUEST)		01/01/2026	Fax Form	Leuprolide-Lupron	ARCHIVED - Leuprolide (Comm-QI)
Fesilty (fibrinogen, human–chmt)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
1. Firazyr (icatibant) (Hereditary Angioedema Preferred Drug Program) (Commercial)		11/21/2025	Refer below for Firazyr Fax Forms	Hereditary Angioedema Preferred Drug Program	ARCHIVED - Hereditary Angioedema Preferred Drug Program
2. Firazyr (icatibant) (Commerical and QUEST)		01/01/2026	Commercial Fax Form QUEST Fax Form	icatibant–Firazir-sajazir	ARCHIVED - Icatibant (Comm-QUEST)
Flebogamma DIF (human immunoglobulin) (Commercial and QUEST)		07/25/2025	Commercial Fax Form QUEST Fax Form	Intravenous Immune Globulin (IVIG)	ARCHIVED - IVIG (Comm-QUEST)
Flebogamma DIF (human immunoglobulin) (Medicare Advantage)		06/26/2026	Medicare Advantage Fax Form	Intravenous Immune Globulin (IVIG) - MA	ARCHIVED - IVIG (MA)
Flolan (epoprostenol) (Commercial and QUEST)		06/01/2026	Fax Form	Flolan; Veletri; epoprostenol (generic)	ARCHIVED - Flolan-Veletri-epoprostenol (Comm-QI) ARCHIVED - Flolan-Veletri
Flolan (epoprostenol) (Medicare Advantage)		12/19/2025	Medicare Advantage Fax Form	Flolan; Veletri; epoprostenol (generic) MA	ARCHIVED - Flolan-Veletri-epoprostenol (MA)
Folotyn (pralatrexate)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Forteo (teriparatide)		06/27/2025	Fax Form		ARCHIVED - Forteo
Forzinity (elamipretide)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Added effective 11/18/2025	ARCHIVED - SDRP
Fulphila (pegfilgrastim-jmdb) (Commercial)	No PA Required	01/01/2026		Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program	ARCHIVED - CSF Long Acting Preferred Drug Program
Fulphila (pegfilgrastim-jmdb) (Medicare Advantage)	No PA Required	01/01/2026		Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program	ARCHIVED - CFS Long Acting Preferred Drug Program (MA)
Fyarro (sirolimus protein-bound particles for injectable suspension)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Added effective 4/1/2022	ARCHIVED - Global Oncology
Fylnetra (pegfilgrastim-pbbk) (Commercial)		01/01/2026	Commercial Fax Form	Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program	ARCHIVED - CSF Long Acting Preferred Drug Program
Fylnetra (pegfilgrastim-pbbk) (Medicare Advantage)		01/01/2026	Medicare Advantage Fax Form	Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program	ARCHIVED - CFS Long Acting Preferred Drug Program (MA)

G

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Gamifant (emapalumab-lzsg)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Gammagard Liquid (human immunoglobulin) (Commercial & QUEST)		07/25/2025	Commercial Fax Form QUEST Fax Form	Intravenous Immune Globulin (IVIG)	ARCHIVED - IVIG (Comm-QUEST)
Gammagard Liquid (human immunoglobulin) (Medicare Advantage)		06/26/2026	Medicare Advantage Fax Form	Intravenous Immune Globulin (IVIG) - MA	ARCHIVED - IVIG (MA)
Gammagard Liquid ERC [immune globulin infusion (human)] (Commercial and QUEST)		07/25/2025	Commercial Fax Form QUEST Fax Form	Intravenous Immune Globulin (IVIG)	ARCHIVED - IVIG (Comm-QUEST)
Gammagard Liquid ERC (Medicare Advantage)		06/26/2026	Medicare Advantage Fax Form	Intravenous Immune Globulin (IVIG) - MA	ARCHIVED - IVIG (MA)
Gammagard S/D (immune globulin) (Commercial & QUEST)		07/25/2025	Commercial Fax Form QUEST Fax Form	Intravenous Immune Globulin (IVIG)	ARCHIVED - IVIG (Comm-QUEST)
Gammagard S/D (immune globulin) (Medicare Advantage)		06/26/2026	Medicare Advantage Fax Form	Intravenous Immune Globulin (IVIG) - MA	ARCHIVED - IVIG (MA)
Gammaked (immune globulin) (Commercial & QUEST)		07/25/2025	Commercial Fax Form QUEST Fax Form	Intravenous Immune Globulin (IVIG)	ARCHIVED - IVIG (Comm-QUEST)
Gammaked (immune globulin) (Medicare Advantage)		06/26/2026	Medicare Advantage Fax Form	Intravenous Immune Globulin (IVIG) - MA	ARCHIVED - IVIG (MA)
Gammaplex (human immunoglobulin) (Commercial & QUEST)		07/25/2025	Commercial Fax Form QUEST Fax Form	Intravenous Immune Globulin (IVIG)	ARCHIVED - IVIG (Comm-QUEST)
Gammaplex (human immunoglobulin) (Medicare Advantage)		06/26/2026	Medicare Advantage Fax Form	Intravenous Immune Globulin (IVIG) - MA	ARCHIVED - IVIG (MA)
Gamunex (Medicare Advantage)		06/26/2026	Medicare Advantage Fax Form	Intravenous Immune Globulin (IVIG) - MA	ARCHIVED - IVIG (MA)
Gamunex-C (human immunoglobulin) (Commercial & QUEST)		07/25/2025	Commercial Fax Form QUEST Fax Form	Intravenous Immune Globulin (IVIG)	ARCHIVED - IVIG (Comm-QUEST)
Gamunex-C (human immunoglobulin) (Medicare Advantage)		06/26/2026	Medicare Advantage Fax Form	Intravenous Immune Globulin (IVIG) - MA	ARCHIVED - IVIG (MA)
Gattex (teduglutide) (Commercial and QUEST)	No PA required for Medicare Advantage effective 1/1/2024	04/01/2026	Fax Form		ARCHIVED - Gattex
Gazyva (obinutuzumab)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Gazyva (obinutuzumab) (non-oncology) (Commercial and QUEST)		07/01/2026			ARCHIVED - Gazyva (Comm-QUEST)
1. Gel-One® (Hyaluronates Preferred Drug Program) (Commercial and QUEST)		01/01/2026	See below for Gel-One® Commercial Fax Form	Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (Commercial)
2. Gel-One® (cross-linked hyaluronate) (Commercial and QUEST)		06/26/2026	Commercial Fax Form QUEST Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QUEST) ARCHIVED - Hyaluronates (drug specific)
1. Gel-One (Hyaluronates Preferred Drug Program) (Medicare Advantage)		01/01/2026	See below for Gel-One® Medicare Advantage Fax Form	Hyaluronates Preferred Drug Program MA	ARCHIVED - Hyaluronates Preferred Drug Program) (MA)
2. Gel-One® (cross-linked hyaluronate) (Medicare Advantage)		03/13/2026	Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)
1. Gelsyn-3 (Hyaluronates Preferred Drug Program) (Commercial and QUEST)		01/01/2026	See below for Gelsyn-3 Commercial Fax Form	Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (Commercial)
2. Gelsyn-3 (sodium hyaluronate 0.84%) (Commercial and QUEST)		06/26/2026	Commercial Fax Form QUEST Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QUEST) ARCHIVED - Hyaluronates (drug specific)
1. Gelsyn-3 (Hyaluronates Preferred Drug Program) (Medicare Advantage)		01/01/2026	See below for Gelsyn-3 Medicare Advantage Fax Form	Hyaluronates Preferred Drug Program MA	ARCHIVED - Hyaluronates Preferred Drug Program) (MA)
2. Gelsyn-3 (sodium hyaluronate 0.84%) (Medicare Advantage)		03/13/2026	Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)
Genotropin (somatropin) (Commercial and QUEST)		01/01/2026	Fax Form	Growth Hormone	ARCHIVED - Growth Hormone
1. Genvisc 850 (Hyaluronates Preferred Drug Program) (Commercial and QUEST)		01/01/2026	See below for Genvisc 850 Commercial Fax Form	Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (Commercial)
2. Genvisc 850 (sodium hyaluronate) (Commercial and QUEST)		06/26/2026	Commercial Fax Form QUEST Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QUEST) ARCHIVED - Hyaluronates (drug specific)
1. GenVisc 850 (Hyaluronates Preferred Drug Program) (Medicare Advantage)		01/01/2026	See below for Genvisc 850 Medicare Advantage Fax Form	Hyaluronates Preferred Drug Program MA	ARCHIVED - Hyaluronates Preferred Drug Program) (MA)
2. Genvisc 850 (sodium hyaluronate) (Medicare Advantage)		03/13/2026	Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)
Givlaari (givosiran)	Effective 02/15/2024: Please contact HMSA at 808-948-6464, option #4, for drug review			Effective 2/15/2024 PA review for Givlaari is moved from CVS to HMSA review	ARCHIVED - SDRP
Glassia (alpha-1 proteinase inhibitor)		06/12/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Added effective 07/01/2025	ARCHIVED - SDRP
Global Oncology		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Gonal-f (Commercial)		12/19/2025	Fax Form		ARCHIVED - Gonal-f (Comm)
Granix (TBO-filgrastim) (CSF Short Acting Preferred Drug Program Commercial and QUEST)		11/21/2025	Commercial Fax Form QUEST Fax Form	Colony Stimulating Factors (CSF) – Short Acting Preferred Drug Program	ARCHIVED - CSF Short Acting Preferred Drug Program
Granix (TBO-filgrastim) (CSF Short Acting Preferred Drug Program Medicare Advantage)		11/21/2025	Medicare Advantage Fax Form	CSF–Short Acting Preferred Drug Program	ARCHIVED - CSF Short Acting (Preferred Drug Program) (MA)
Grafapex (treosulfan)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Added effective 02/28/2025	ARCHIVED - Global Oncology
Growth Hormone (Commercial and QUEST)		01/01/2026		Growth Hormone	ARCHIVED - Growth Hormone

H

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
1. Hadlima (adalimumab-bwwd) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026		Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Hadlima (adalimumab-bwwd) (Commercial)		05/25/2025	Commercial Fax Form	Humira (adalimumab) Effective 12/01/2023	ARCHIVED - Adalimumab (Humira)
Hadlima (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QUEST)
Haegarda (C1 esterase inhibitor [human])		06/12/2026	Commercial Fax Form QUEST Fax Form	Specialty Drugs Requiring Precertification (SDRP) Drug is not covered under Part B	ARCHIVED - SDRP
Hemgenix (etranacogene dezaparvovec-drlb)	Please contact HMSA at 808-948-6464, option #4, for drug review
Hemlibra (emicizumab)	Please contact HMSA at 808-948-6464, option #4, for drug review
Hemofil M [Factor VIII (plasma derived)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Hepcludex (bulevirtide-gmod)		06/12/2026	Commercial Fax Form QUEST Fax Form	Specialty Drugs Requiring Precertification (SDRP) Added effective 6/12/2026	ARCHIVED - SDRP
1. Herceptin (trastuzumab) (Trastuzumab Preferred Drug Program Commercial and QUEST)		01/01/2026	Refer below for Herceptin fax forms	Trastuzumab Products - Preferred Drug Program Commercial Effective 1/1/2024	ARCHIVED - Trastuzumab Products (Commercial)
2. Herceptin (trastuzumab) (Commercial and QUEST)		06/12/2026	Commercial Fax Form QUEST Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Herceptin (trastuzumab) (Trastuzumab Preferred Drug Program Medicare Advantage)		01/01/2026	Refer below for Herceptin fax forms	Trastuzumab Products - Preferred Drug Program MA Effective 1/1/2024	ARCHIVED - Trastuzumab Products (MA)
2. Herceptin (trastuzumab) (Medicare Advantage)		06/12/2026	Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Trastuzumab Preferred Drug Program Commercial and QUEST)		01/01/2026	Refer below for Herceptin Hylecta fax forms	Trastuzumab Products - Preferred Drug Program Commercial	ARCHIVED - Trastuzumab Products (Commercial)
2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Commercial and QUEST)		06/12/2026	Commercial Fax Form QUEST Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Trastuzumab Preferred Drug Program Medicare Advantage)		01/01/2026	Refer below for Herceptin Hylecta fax forms	Trastuzumab Products - Preferred Drug Program MA	ARCHIVED - Trastuzumab Products (MA)
2. Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Medicare Advantage)		06/12/2026	Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Hercessi (trastuzumab-stfr)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Hereditary Angioedema (HAE) Acute Preferred Drug Program (Commercial)		11/21/2025		Hereditary Angioedema (HAE) Acute Preferred Drug Program	ARCHIVED - Hereditary Angioedema Preferred Drug Program
1. Herzuma (trastuzumab-pkrb) (Trastuzumab Preferred Drug Program Commercial and QUEST)		01/01/2026	Refer below for Herzuma fax forms	Trastuzumab Products - Preferred Drug Program Commercial	ARCHIVED - Trastuzumab Products (Commercial)
2. Herzuma (trastuzumab-pkrb) (Commercial and QUEST)		06/12/2026	Commercial Fax Form QUEST Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Herzuma (trastuzumab-pkrb) (Trastuzumab Preferred Drug Program Medicare Advantage)		01/01/2026	Refer below for Herzuma fax forms	Trastuzumab Products - Preferred Drug Program MA	ARCHIVED - Trastuzumab Products (MA)
2. Herzuma (trastuzumab-pkrb) (Medicare Advantage)		06/12/2026	Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Hizentra (Immune Globulin Subcutaneous [Human], 20% Liquid) (Commercial and QUEST)		10/01/2025	Commercial Fax Form QUEST Fax Form	Subcutaneous Immunoglobulin (SCIG)	ARCHIVED - SCIG (Comm-QUEST)
Hizentra (Immune Globulin Subcutaneous [Human], 20% Liquid) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Subcutaneous Immunoglobulin (SCIG)	ARCHIVED - SCIG (MA)
HP Acthar Gel (repository corticotropin injection) (Commercial and QUEST)		12/19/2025	Fax Form		ARCHIVED - HP Acthar Gel (Comm-QUEST)
1. Hulio (adalimumab-fkjp) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026		Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Hulio (adalimumab-fkjp) (Commercial)		05/25/2025	Commercial Fax Form	Humira (adalimumab) Effective 12/01/2023	ARCHIVED - Adalimumab (Humira)
Hulio (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QUEST)
Humate P [Factor VIII (plasma derived)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Humatrope (somatropin) (Commercial and QUEST)				Discontinued as of 12/31/2025	ARCHIVED - Growth Hormone
1. Humira (adalimumab) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Humira Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Humira (adalimumab) (Commerical)		05/25/2025	Commercial Fax Form	Adalimumab (Humira)	ARCHIVED - Adalimumab (Humira)
Humira (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QUEST)
1. Hyalgan® (Hyaluronates Preferred Drug Program) (Commercial and QUEST)		01/01/2026	See below for Hyalgan® Commercial Fax Form	Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (Commercial)
2. Hyalgan® (sodium hyaluronate) (Commercial and QUEST)		04/12/2026	Commercial Fax Form QUEST Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QUEST) ARCHIVED - Hyaluronates (drug specific)
1. Hyalgan (Hyaluronates Preferred Drug Program) (Medicare Advantage)		01/01/2026	See below for Hyalgan® Medicare Advantage Fax Form	Hyaluronates Preferred Drug Program MA	ARCHIVED - Hyaluronates Preferred Drug Program) (MA)
2. Hyalgan® (sodium hyaluronate) (Medicare Advantage)		03/13/2026	Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)
Hyaluronates Preferred Drug Program (Commercial and QUEST)		01/01/2026		Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (Commercial)
Hyaluronates (Commercial and QUEST)		06/26/2026		Hyaluronates	ARCHIVED - Hyaluronates (Comm-QUEST) ARCHIVED - Hyaluronates (drug specific)
Hyaluronates Preferred Drug Program (Medicare Advantage)		01/01/2026		Hyaluronates Preferred Drug Program MA	ARCHIVED - Hyaluronates Preferred Drug Program) (MA)
Hyaluronates (Medicare Advantage)		03/13/2026		Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)
hydroxyprogesterone caproate (generic)				Makena (hydroxyprogesterone caproate injection)	ARCHIVED - Makena
1. Hymovis (Hyaluronates Preferred Drug Program) (Commercial and QUEST)		01/01/2026	See below for Hymovis Commercial Fax Form	Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (Commercial)
2. Hymovis (high molecular weight viscoelastic hyaluronan) (Commercial and QUEST)		06/26/2026	Commercial Fax Form QUEST Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QUEST) ARCHIVED - Hyaluronates (drug specific)
1. Hymovis (Hyaluronates Preferred Drug Program) (Medicare Advantage)		01/01/2026	See below for Hymovis Medicare Advantage Fax Form	Hyaluronates Preferred Drug Program MA	ARCHIVED - Hyaluronates Preferred Drug Program) (MA)
2. Hymovis (high molecular weight viscoelastic hyaluronan) (Medicare Advantage)		03/13/2026	Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)
Hymovis One (high molecular weight viscoelastic hyaluronan) (Commercial and QUEST)		06/26/2026	Commercial Fax Form QUEST Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QUEST)
Hymovis One (high molecular weight viscoelastic hyaluronan) (Medicare Advantage)		03/13/2026	Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)
Hympavzi [Tissue Factor Pathway Inhibitor (marstacimab-hncq)]	Please contact HMSA at 808-948-6464, option #4, for drug review.
HyQvia (Immune Globulin Infusion 10% [Human] with Recombinant Human Hyaluronidase)(Commercial and QUEST)		10/01/2025	Commercial Fax Form QUEST Fax Form	Subcutaneous Immunoglobulin (SCIG)	ARCHIVED - SCIG (Comm-QUEST)
HyQvia (Immune Globulin Infusion 10% [Human] with Recombinant Human Hyaluronidase) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Subcutaneous Immunoglobulin (SCIG)	ARCHIVED - SCIG (MA
1. Hyrimoz (adalimumab-adaz) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026		Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Hyrimoz (adalimumab-adaz) (Commercial)		05/25/2025	Commercial Fax Form	Humira (adalimumab) Effective 12/01/2023	ARCHIVED - Adalimumab (Humira)
Hyrimoz (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QUEST)

I

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
1. Icatibant (Hereditary Angioedema Preferred Drug Program) (Commercial)		11/21/2025	Refer below for icatibant Fax Forms	Hereditary Angioedema Preferred Drug Program	ARCHIVED - Hereditary Angioedema Preferred Drug Program
2. icatibant (generic) (Commercial and QUEST)		01/01/2026	Commercial Fax Form QUEST Fax Form	icatibant–Firazir-sajazir	ARCHIVED - Icatibant (Comm-QUEST)
1. Idacio (adalimumab-aacf) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026		Commercial plan members refer to the Preferred Drug Program policy first.	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Idacio (adalimumab-aacf) (Commercial)		05/25/2025	Commercial Fax Form	Humira (adalimumab) Effective 12/1/2023	ARCHIVED - Adalimumab (Humira)
Idacio (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QI)
Idelvion [Factor IX (recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Ilaris (canakinumab) (Commercial and QUEST)		10/01/2025	Fax Form		ARCHIVED - Ilaris (Comm-QI) ARCHIVED - Ilaris
Ilaris (canakinumab) (Medicare Advantage)		06/26/2026			ARCHIVED - Ilaris (MA) ARCHIVED - Ilaris
1. Ilumya (tildrakizumab-asmn) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Ilumya Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Ilumya (tildrakixumab-asmn) (Commercial and QUEST)		03/27/2026	Commerical Fax Form QUEST Fax Form	Specific drug criteria for Ilumya eff 10/1/2020	ARCHIVED - Ilumya (COMM-QI) ARCHIVED - Ilumya
Ilumya (tildrakixumab-asmn) (Medicare Advantage)		03/27/2026	Medicare Advantage Fax Form		ARCHIVED - Ilumya (MA)
Imaavy (nipocalimab-aahu)		06/12/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Added effective 7/10/2023	ARCHIVED - SDRP
Imdelltra (tarlatamab-dlle)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Imfinzi (durvalumab)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Imjudo (durvalumab)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Imlygic (talimogene laherparepvec)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Imuldosa (ustekinumab-srlf) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	See below for Imuldosa Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Imuldosa (ustekinumab-srlf) (Commercial)		01/19/2026	Commercial Fax Form	Stelara and Biosimilars Added eff 4/8/2025	ARCHIVED - Stelara and Biosimilars (Commercial)
Imuldosa (ustekinumab-srlf) (QUEST)		01/19/2026	QUEST Fax Form	Stelara and Biosimilars (QUEST)	ARCHIVED - Stelara and Biosimilars (QUEST)
Imuldosa (ustekinumab-srlf) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Stelara and Biosimilars (Medicare Advantage)	ARCHIVED - Stelara (MA)
1. Inflectra (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	See below for Inflectra Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Inflectra (infliximab-dyyb) (Commercial)		04/01/2026	Commercial Fax Form	Infliximab-Avsola-Inflectra-Remicade-Renflexis-Zymfentra	ARCHIVED - Infliximab (Comm-QUEST) ARCHIVED - Infliximab
Inflectra (infliximab-dyyb) (QUEST)		07/01/2026	QUEST Fax Form	Infliximab-Avsola-Inflectra-Renflexis-Zymfentra (QUEST)	ARCHIVED - Infliximab (QUEST)
Inflectra (infliximab-dyyb) (Medicare Advantage)		12/19/2025	Medicare Advantage Fax Form	Infliximab-Avsola-Inflectra-Remicade-Renflexis MA	ARCHIVED - Infliximab (MA)
Infliximab (Commercial)		04/01/2026	Commercial Fax Form	Infliximab-Avsola-Inflectra-Remicade-Renflexis-Zymfentra	ARCHIVED - Infliximab (Comm-QUEST) ARCHIVED - Infliximab
Infliximab (QUEST)		07/01/2026	QUEST Fax Form	Infliximab-Avsola-Inflectra-Renflexis-Zymfentra (QUEST)	ARCHIVED - Infliximab (QUEST)
Infliximab (Medicare Advantage)		12/19/2025	Medicare Advantage Fax Form	Infliximab-Avsola-Inflectra-Remicade-Renflexis MA	ARCHIVED - Infliximab (MA)
Infugem (gemcitabine)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Inlexzo (gemcitabine)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Intravenous Immune Globulin (IVIG) (Commercial & QUEST)		07/25/2025	Fax Form	Intravenous Immune Globulin (IVIG)	ARCHIVED - IVIG
Intravenous Immune Globulin (IVIG) (Medicare Advantage)		06/26/2026	Medicare Advantage Fax Form	Intravenous Immune Globulin (IVIG) - MA	ARCHIVED - IVIG (MA)
Istodax (romidepsin)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Effective 8/1/2022	ARCHIVED - Global Oncology
Ivra (melphalan hydrochloride)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Added effective 3/23/2025	ARCHIVED - Global Oncology
Ixinity [Factor IX (recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Izervay (avacincaptad pegol intravitreal solution)		06/12/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Effective 9/1/2023	ARCHIVED - SDRP

J

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Jelmyto (mitomycin)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Jemperli (dostarlimab-gxly)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology (eff 05/01/2021)	ARCHIVED - Global Oncology
Jetrea				No PA required as of 3/1/19
Jivi [Factor VIII (recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Jobevne (bevacizumab-nwgd) (Bevacizumab Preferred Drug Program policy Commercial)		01/01/2026	Commercial Fax Form	Bevacizumab Products - Preferred Drug Program Commercial Effective 1/1/2026	ARCHIVED - Bevacizumab Products (Commercial)
Jobevne (bevacizumab-nwgd) (Bevacizumab Preferred Drug Program policy Medicare Advantage)		01/01/2026	Medicare Advantage Fax Form	Bevacizumab Products - Preferred Drug Program Medicare Advantage Effective 1/1/2026	ARCHIVED - Bevacizumab Products (MA)
Jobevne (bevacizumab-nwgd) (Bevacizumab Preferred Drug Program policy QUEST)		01/01/2026		Bevacizumab Products - Preferred Drug Program QUEST Effective 1/1/2026	ARCHIVED - Bevacizumab Products (QUEST)
Jubbonti (denosumab-bbdz) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Prolia and Biosimilars (Commercial and QUEST)	ARCHIVED - Prolia (Comm-QUEST)
Jubbonti (denosumab-bbdz) (Medicare Advantage)	60-day provider notice 08/01/2026-09/30/2026, in effect 10/01/2026	06/27/2025	Medicare Advantage Fax Form	Prolia and Biosimilars (Medicare Advantage) Added eff 6/27/2025	ARCHIVED - Prolia (MA)

K

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Kadcyla (ado-trastuzumab emtansine)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Kalbitor (ecallantide) (Hereditary Angioedema Preferred Drug Program) (Commercial)		11/21/2025	Refer below for Kalbitor Fax Forms	Hereditary Angioedema Preferred Drug Program Added effective 2/1/2022	ARCHIVED - Hereditary Angioedema Preferred Drug Program
2. Kalbitor (ecallantide) (Commercial and QUEST)		01/01/2026	Fax Form QUEST Fax Form	Specific drug criteria	ARCHIVED - Kalbitor (Comm-QUEST) ARCHIVED - Kalbitor
Kalbitor (ecallantide) (Medicare Advantage)		01/01/2026	Medicare Advantage Fax Form		ARCHIVED - Kalbitor (MA)
1. Kanjinti (trastuzumab-anns) (Trastuzumab Preferred Drug Program Commercial and QUEST)		01/01/2026	Refer below for Kanjinti fax forms	Trastuzumab Products - Preferred Drug Program Commercial	ARCHIVED - Trastuzumab Products (Commercial)
2. Kanjinti (trastuzumab-anns) (Commercial and QUEST)		06/12/2026	Commercial Fax Form QUEST Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Kanjinti (trastuzumab-anns) (Trastuzumab Preferred Drug Program Medicare Advantage)		01/01/2026	Refer below for Kanjinti fax forms	Trastuzumab Products - Preferred Drug Program MA	ARCHIVED - Trastuzumab Products (MA)
2. Kanjinti (trastuzumab-anns) (Medicare Advantage)		06/12/2026	Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Kanuma (sebelipase alfa)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Kepivance (palifermin)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Added effective 11/28/2023	ARCHIVED - Global Oncology
Kesimpta (ofatumumab)		06/12/2026	Commercial Fax Form QUEST Fax Form	Specialty Drugs Requiring Precertification (SDRP) Drug is not covered under Part B	ARCHIVED - SDRP
1. Kevzara (sarilumab) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Kevzara Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Kevzara (sarilumab) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Specific drug criteria for Kevzara eff 10/1/2020	ARCHIVED - Kevzara (Comm-QUEST)
Keytruda (pembrolizumab)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Keytruda Qlex (pembrolizumab and berahyaluronidase alfa)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Added effective 5/18/2026	ARCHIVED - Global Oncology
Khapzory (levoleucovorin)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Kimmtrak (tebentafusp-tebn)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Added effective 4/1/2022	ARCHIVED - Global Oncology
1. Kineret (anakinra) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Kineret Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Kineret (anakinra) (Commercial and QUEST)		05/23/2025	Fax Form	Specific drug criteria for Kineret	ARCHIVED - Kineret
Kisunla (donanemab-azbt)	Please contact HMSA at 808-948-6464, option #4, for drug review				ARCHIVED - SDRP
Koate [Factor VIII (plasma derived)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Kovaltry Factor VIII (recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Krystexxa (pegloticase) (Commercial and QUEST)		06/26/2026	Fax Form		ARCHIVED - Krystexxa (Comm-QI) ARCHIVED - Krystexxa
Krystexxa (pegloticase) (Medicare Advantage)		06/26/2026	Medicare Advantage Fax Form		ARCHIVED - Krystexxa (MA)
Kymriah	Effective 06/24/2019: Please contact HMSA at 808-948-6464, option #4, for drug review
Kynamro (mipomersen)				No PA required as of 05/25/2021
Kyprolis (carfilzomib)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Kyxata (carboplatin)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Added effective 09/12/2025	ARCHIVED - Global Oncology

L

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Lamzede (velmanase alfa-tycv)		06/12/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) eff 4/1/2023	ARCHIVED - SDRP
Lanreotide (lanreotide acetate injection) (non-oncology) (Commercial and QUEST)		09/26/2025		Somatuline Depot-Lanreotide	ARCHIVED - Lanreotide (Comm-QI)
Lanreotide (lanreotide acetate injection) (non-oncology) (Medicare Advantage)		10/27/2025		Somatuline Depot-Lanreotide MA	ARCHIVED - Lanreotide (MA)
Lantidra (donislecel-jujn)	Please contact HMSA at 808-948-6464, option #4, for drug review
Leqembi (lecanemab-irmb)		02/01/2025	Commercial Fax Form QUEST Fax Form		ARCHIVED - Leqembi
Leqvio (inclisiran)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) eff 4/1/2022	ARCHIVED - SDRP
Leukine (sargramostim) (CSF Short Acting Preferred Drug Program Commercial and QUEST)		11/21/2025	Commercial Fax Form QUEST Fax Form	Colony Stimulating Factors (CSF) – Short Acting Preferred Drug Program	ARCHIVED - CSF Short Acting Preferred Drug Program
Leukine (sargramostim) (CSF Short Acting Preferred Drug Program Medicare Advantage)		11/21/2025	Medicare Advantage Fax Form	Colony Stimulating Factors (CSF) –Short Acting Preferred Drug Program	ARCHIVED - CSF Short Acting (Preferred Drug Program) (MA)
leuprolide acetate (generic) (Non-oncology) (Commercial and QUEST)		01/01/2026	Fax Form	Leuprolide-Lupron	ARCHIVED - Leuprolide (Comm-QUEST)
leuprolide acetate (generic) (Oncology)		06/12/2026	Fax Form	Global Oncology	ARCHIVED - Global Oncology
Libtayo (cemiplimab-rwlc)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Loqtorzi (toripalimab-tpzi)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology Effective 12/12/2023
Lucentis (ranibizumab) (Commercial and QUEST)	No PA required
Lucentis (ranibizumab) (Medicare Advantage)	No PA required as of 01/01/2024			Retinal Disorders Preferred Drug Program	ARCHIVED - Retinal Disorders Preferred Drug Program (MA)
Lumoxiti (moxetumomab pasudotox-TDFK)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Lunsumio (mosunetuzumab-axgb)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Effective 1/20/2023	ARCHIVED - Global Oncology
Lupaneta Pack (Non-oncology)	No PA required. Drug was discontinued as of 4/1/2024.			Lupron-Lupaneta	ARCHIVED - Lupron-Lupaneta
Lupron Depot (leuprolide acetate) (Commercial and QUEST)	No PA Required for Medicare Advantage	01/01/2026	Fax Form	Leuprolide-Lupron	ARCHIVED - Leuprolide (Comm-QUEST)
Lupron Depot (leuprolide acetate) (Oncology)	No PA Required for Medicare Advantage	06/12/2026	Fax Form	Global Oncology	ARCHIVED - Global Oncology
Lupron Depot-PED (leuprolide acetate) (Non-oncology) (Commercial and QUEST)		01/01/2026	Fax Form	Leuprolide-Lupron	ARCHIVED - Leuprolide (Comm-QUEST)
Lutathera	Effective 06/24/2019: Please contact HMSA at 808-948-6464, option #4, for drug review
Luxturna (voretigene neparvovec-rzyl)	Please contact HMSA at 808-948-6464, option #4, for drug review
Lyfgenia (lovotibeglogene autotemcel)	Please contact HMSA at 808-948-6464, option #4, for drug review
Lymphir (denileukin diftitox-cxdl)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Added effective 12/23/2025	ARCHIVED - Global Oncology
Lynozyfic (linvoseltamab-gcpt)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Added effective 07/17/2025	ARCHIVED - Global Oncology

M

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Macugen (pegaptanib sodium) (Commercial and QUEST)	No PA required				ARCHIVED - Retinal Disorders Preferred Drug Program
Macugen (pegaptanib sodium) (Medicare Advantage)	No PA required as of 02/01/2022			Retinal Disorders Preferred Drug Program	ARCHIVED - Retinal Disorders Preferred Drug Program (MA)
Makena (hydroxyprogesterone caproate injection)	As of 04/06/2023 this drug is no longer available				ARCHIVED - Makena
Margenza (margetuximab-cmkb)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Mepsevii (vestronidase alfa-vjbk)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Monjuvi (tafasitamab-cxix)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Mononine Factor IX (plasma derived)]	Please contact HMSA at 808-948-6464, option #4, for drug review
1. Monovisc™ (Hyaluronates Preferred Drug Program) (Commercial and QUEST)		01/01/2026	See below for Monovisc™ Commercial Fax Form	Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (Commercial)
2. Monovisc™ (high molecular weight hyaluronan) (Commercial and QUEST)		06/26/2026	Commercial Fax Form QUEST Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QUEST) ARCHIVED - Hyaluronates (drug specific)
1. Monovisc (Hyaluronates Preferred Drug Program) (Medicare Advantage)		01/01/2026	See below for Monovisc™ Medicare Advantage Fax Form	Hyaluronates Preferred Drug Program MA	ARCHIVED - Hyaluronates Preferred Drug Program) (MA)
2. Monovisc™ (high molecular weight hyaluronan) (Medicare Advantage)		03/13/2026	Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)
Mozobil (plerixafor) (Commercial and QUEST)		06/26/2026	Commercial Fax Form QUEST Fax Form	Mozobil (plerixafor) (Commercial and QUEST)	ARCHIVED - Mozobil (Comm-QUEST)
Multiple Sclerosis (MS) – Interferons Preferred Drug Program (Commercial)		11/21/2025		Multiple Sclerosis (MS) – Interferons Preferred Drug Program	ARCHIVED - Multiple Sclerosis (MS) – Preferred Drug Program
1. Mvasi (bevacizumab-awwb) (Bevacizumab Preferred Drug Program Commercial)		01/01/2026	Commercial Fax Form	Bevacizumab Products - Preferred Drug Program Commercial Effective 1/1/2024	ARCHIVED - Bevacizumab Products (Commercial)
2. Mvasi (bevacizumab-awwb) (Commercial)		06/12/2026	Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Mvasi (bevacizumab-awwb) (Bevacizumab Preferred Drug Program Medicare Advantage)		01/01/2026	Medicare Advantage Fax Form	Bevacizumab Products - Preferred Drug Program MA Effective 1/1/2024	ARCHIVED - Bevacizumab Products (MA)
2. Mvasi (bevacizumab-awwb) (Medicare Advantage)		06/12/2026		Global Oncology	ARCHIVED - Global Oncology
1. Mvasi (bevacizumab-awwb) (Bevacizumab Preferred Drug Program QUEST)		01/01/2026		Bevacizumab Products - Preferred Drug Program QUEST Effective 1/1/2025	ARCHIVED - Bevacizumab Products (QUEST)
2. Mvasi (bevacizumab-awwb) (QUEST)		06/12/2026	QUEST Fax Form	Global Oncology	ARCHIVED - Global Oncology
Myalept (metreleptin)		09/26/2025	Fax Form		ARCHIVED - Myalept (Comm-QUEST)
Mylotarg (gemtuzumab ozogamicin)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Myobloc (rimabotulinumtoxinB)		04/01/2026	Fax Form QUEST Fax Form Medicare Advantage Fax Form	Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY)	ARCHIVED - Botulinum Toxins
1. Myobloc (Botulinum Toxins Preferred Drug Program) (Medicare Advantage)		11/21/2025	Refer below for Myobloc Fax Forms	Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY) Preferred Drug Program	ARCHIVED - Botulinum Toxins Preferred Drug Program MA
2. Myobloc (rimabotulinumtoxinB)		04/01/2026	Fax Form QUEST Fax Form Medicare Advantage Fax Form	Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY)	ARCHIVED - Botulinum Toxins

N

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
1. Nemluvio (nemolizumab-ilto) (Atopic Dermatitis Preferred Program) (Commercial)		01/01/2026		Atopic Dermatitis Preferred Program Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Atopic Dermatitis (Commercial)
2.Nemluvio (nemolizumab-ilto) (Commercial)		07/01/2026		Drug specific policy effective 7/1/2026 Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Nemluvio (nemolizumab-ilto) (QUEST)		07/01/2026			ARCHIVED - Nemluvio (QUEST)
Neulasta (including Onpro kit) (pegfilgrastim) (Commercial)	No PA required	01/01/2026		Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program	ARCHIVED - CSF Long Acting Preferred Drug Program
Neulasta (including Onpro kit) (pegfilgrastim) (Medicare Advantage)	No PA required	01/01/2026		Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program	ARCHIVED - CFS Long Acting Preferred Drug Program (MA)
Neupogen (filgrastim) (CSF Short Acting Preferred Drug Program Commercial and QUEST)		11/21/2025	Commercial Fax Form QUEST Fax Form	Colony Stimulating Factors (CSF) – Short Acting Preferred Drug Program	ARCHIVED - CSF Short Acting Preferred Drug Program
Neupogen (filgrastim) (CSF Short Acting Preferred Drug Program Medicare Advantage)		11/21/2025	Medicare Advantage Fax Form	Colony Stimulating Factors (CSF) – Short Acting Preferred Drug Program	ARCHIVED - CSF Short Acting (Preferred Drug Program) (MA)
Nexviazyme (avalglucosidase alfa-ngpt)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Ngenla (somatrogon-ghla)		06/12/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Added effective 9/1/2023	ARCHIVED - SDRP
Niktimvo (axatilimab-csfr)		06/12/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Nivestym (filgrastim-aafi) (CSF Short Acting Preferred Drug Program Commercial and QUEST)		11/21/2025	Commercial Fax Form QUEST Fax Form	Colony Stimulating Factors (CSF) – Short Acting Preferred Drug Program	ARCHIVED - CSF Short Acting Preferred Drug Program
Nivestym (filgrastim-aafi) (CSF Short Acting Preferred Drug Program Medicare Advantage)		11/21/2025	Medicare Advantage Fax Form	Colony Stimulating Factors (CSF) – Short Acting Preferred Drug Program	ARCHIVED - CSF Short Acting (Preferred Drug Program) (MA)
Norditropin® (somatropin) (Commercial and QUEST)		01/01/2026	Fax Form	Growth Hormone	ARCHIVED - Growth Hormone
NovoEight [Factor VIII (recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
NovoSeven RT [Factor VIIA (recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Nplate (romiplostim) (Commercial and QUEST)		11/21/2025	Fax Form		ARCHIVED - Nplate (Comm-QUEST) ARCHIVED - Nplate
Nplate (romiplostim) (Medicare Advantage)		11/21/2025	Medicare Advantage Fax Form		ARCHIVED - Nplate (MA)
Nucala (mepolizumab)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Nulibry (fosdenopterin)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Nutropin/Nutropin AQ (somatropin)	Effective 12/31/2024 Nutropin/Nutropin AQ is discontinued	10/01/2024	Fax Form	Growth Hormone Therapy Preferred Drug Program	ARCHIVED - Growth Hormone
Nuwiq [Factor VIII (recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Nyvepria (pegfilgrastim-apgf) (Commercial)	No PA required	01/01/2026		Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program	ARCHIVED - CSF Long Acting Preferred Drug Program
Nyvepria (pegfilgrastim-apgf) (Medicare Advantage)	No PA required	01/01/2026		Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program	ARCHIVED - CFS Long Acting Preferred Drug Program (MA)

O

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Ocrevus (ocrelizumab)		06/26/2026	Commercial Fax Form QUEST Fax Form	Drug specific criteria effective on 08/01/2025	ARCHIVED - Ocrevus ARCHIVED - SDRP
Ocrevus-Zunovo (ocrelizumab and hysluronidase-ocsq)		06/26/2026	Commercial Fax Form QUEST Fax Form	Drug specific criteria effective on 08/01/2025	ARCHIVED - Ocrevus ARCHIVED - SDRP
Octagam (human immunoglobulin) (Commercial & QUEST)		07/25/2025	Commercial Fax Form QUEST Fax Form	Intravenous Immune Globulin (IVIG)	ARCHIVED - IVIG
Octagam (human immunoglobulin) (Medicare Advantage)		06/26/2026	Medicare Advantage Fax Form	Intravenous Immune Globulin (IVIG) - MA	ARCHIVED - IVIG (MA)
Off-Label (Commercial & QUEST)	Refer to Criteria Exception (Commercial & QUEST) policy				ARCHIVED - Off-Label (Commerical & QUEST)
Off-Label (Medicare Advantage)		09/26/2025			ARCHIVED - Off Label (MA)
1. Ogivri (trastuzumab-dkst) (Trastuzumab Preferred Drug Program Commercial and QUEST)		01/01/2026	Refer below for Ogivri fax forms	Trastuzumab Products - Preferred Drug Program Commercial Effective 1/1/2024	ARCHIVED - Trastuzumab Products (Commercial)
2. Ogivri (trastuzumab-dkst) (Commercial and QUEST)		06/12/2026	Commercial Fax Form QUEST Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Ogivri (trastuzumab-dkst) (Trastuzumab Preferred Drug Program Medicare Advantage)		01/01/2026	Refer below for Ogivri fax forms	Trastuzumab Products - Preferred Drug Program MA Effective 1/1/2024	ARCHIVED - Trastuzumab Products (MA)
2. Ogivri (trastuzumab-dkst) (Medicare Advantage)		06/12/2026	Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Omisirge (omidubicel-onlv)	Please contact HMSA at 808-948-6464, option #4, for drug review
Omlyclo (omalizumab-igec) (Commercial and QUEST)		12/19/2025	Commercial Fax Form QUEST Fax Form	Xolair Added effective 12/19/2025	ARCHIVED - Xolair (Comm-QUEST)
Omlyclo (omalizumab-igec) (Medicare Advantage)		01/19/2026	Medicare Advantage Fax Form	Xolair-Omlyclo	ARCHIVED - Xolair (MA)
Omnitrope® (somatropin) (Commercial and QUEST)		01/01/2026	Fax Form	Growth Hormone	ARCHIVED - Growth Hormone
1. Omvoh (mirikizumab-mrkz) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Omvoh Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first.	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Omvoh (mirikizumab-mrkz)		06/12/2026	Commercial Fax Form	Specialty Drugs Requiring Precertification (SDRP) Effective 11/1/2023	ARCHIVED - SDRP
Onapgo (apomorphine hydrochloride)		06/12/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Added eff 03/01/2025	ARCHIVED - SDRP
Onivyde (irinotecan hydrochloride)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Onpattro (patisiran)	Effective 02/15/2024: Please contact HMSA at 808-948-6464, option #4, for drug review			Effective 2/15/2024 PA review for Onpattro is moved from CVS to HMSA review	ARCHIVED - SDRP
1. Ontruzant (trastuzumab-dttb) (Trastuzumab Preferred Drug Program Commercial and QUEST)		01/01/2026	Refer below for Ontruzant fax forms	Trastuzumab Products - Preferred Drug Program Commercial Effective 1/1/2024	ARCHIVED - Trastuzumab Products (Commercial)
2. Ontruzant (trastuzumab-dttb) (Commercial and QUEST)		06/12/2026	Commercial Fax Form QUEST Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Ontruzant (trastuzumab-dttb) (Trastuzumab Preferred Drug Program Medicare Advantage)		01/01/2026	Refer below for Ontruzant fax forms	Trastuzumab Products - Preferred Drug Program MA Effective 1/1/2024	ARCHIVED - Trastuzumab Products (MA)
2. Ontruzant (trastuzumab-dttb) (Medicare Advantage)		06/12/2026	Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Opdivo (nivolumab)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Opdualag (nivolumab and relatlimab-rmbw)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Effective 4/1/2022	ARCHIVED - Global Oncology
1. Orencia (abatacept) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Orencia Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Orencia (abatacept) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Specific drug criteria for Orencia	ARCHIVED - Orencia (Comm-QUEST) ARCHIVED - Orencia
Orencia (abatacep) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form		ARCHIVED - Orencia (MA)
1. Orthovisc® (Hyaluronates Preferred Drug Program) (Commercial and QUEST)		01/01/2026	See below for Orthovisc® Commercial Fax Form	Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (Commercial)
2. Orthovisc® (high molecular weight hyaluronan) (Commercial and QUEST)		06/26/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QI) ARCHIVED - Hyaluronates (drug specific)
1. Orthovisc (Hyaluronates Preferred Drug Program) (Medicare Advantage)		01/01/2026	See below for Orthovisc® Medicare Advantage Fax Form	Hyaluronates Preferred Drug Program MA	ARCHIVED - Hyaluronates Preferred Drug Program (MA)
2. Orthovisc® (high molecular weight hyaluronan) (Medicare Advantage)		03/13/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)
Osenvelt (denosumab-bmwo) (Commercial and QUEST)		06/27/2025	Commercial Fax Form QUEST Fax Form	Xgeva and Biosimilars (Commercial and QUEST) Added eff 6/27/2025	ARCHIVED - Xgeva (Comm-QUEST)
Osenvelt (denosumab-bmwo) (Medicare Advantage)		06/27/2025	Medicare Advantage Fax Form	Xgeva and Biosimilars (Medicare Advantage) Added eff 6/27/2025	ARCHIVED - Xgeva (MA)
Ospomyv (denosumab-dssb) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Prolia and Biosimilars (Commercial and QUEST)	ARCHIVED - Prolia (Comm-QUEST)
Ospomyv (denosumab-dssb) (Medicare Advantage)	60-day provider notice 08/01/2026-09/30/2026, in effect 10/01/2026	06/27/2025	Medicare Advantage Fax Form	Prolia and Biosimilars (Medicare Advantage) Added eff 6/27/2025	ARCHIVED - Prolia (MA)
Osvyrti (denosumab-desu) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Prolia and Biosimilars (Commercial and QUEST)	ARCHIVED - Prolia (Comm-QUEST)
Osvyrti (denosumab-desu) (Medicare Advantage)	60-day provider notice 08/01/2026-09/30/2026, in effect 10/01/2026	06/27/2025	Medicare Advantage Fax Form	Prolia and Biosimilars (Medicare Advantage) Added eff 6/27/2025	ARCHIVED - Prolia (MA)
1. Otulfi (ustekinumab-aauz) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026		Commercial plan members refer to the Preferred Drug Program policy first.	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Otulfi (ustekinumab-aauz) (Commercial)		01/19/2026	Commercial Fax Form	Stelara and Biosimilars (Commercial) Added eff 4/8/2025	ARCHIVED - Stelara and Biosimilars (Commercial)
Otulfi (ustekinumab-aauz) (QUEST)		01/19/2026	QUEST Fax Form	Stelara and Biosimilars (QUEST)	ARCHIVED - Stelara and Biosimilars (QUEST)
Otulfi (ustekinumab-aauz) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Stelara and Biosimilars (Medicare Advantage)	ARCHIVED - Stelara (MA)
Oxlumo (lumasiran)	Effective 02/15/2024: Please contact HMSA at 808-948-6464, option #4, for drug review			Effective 2/15/2024 PA review for Oxlumo is moved from CVS to HMSA review	ARCHIVED - SDRP

P

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Padcev (enfortumab vedotin-ejfv)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Palynziq (pegvaliase-pqpz)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Panzyga (immune globulin) (Commercial & QUEST)		07/25/2025	Commercial Fax Form QUEST Fax Form	Intravenous Immune Globulin (IVIG)	ARCHIVED - IVIG (Comm-QI)
Panzyga (immune globulin) (Medicare Advantage		06/26/2026	Medicare Advantage Fax Form	Intravenous Immune Globulin (IVIG) - MA	ARCHIVED - IVIG (MA)
Papzimeos (zopapogene imadenovec-drba)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Added effective 09/12/2025	ARCHIVED - SDRP
Parsabiv (etelcalcetide)	No PA required as of 1/1/2024			New Medical Specialty policy effective 11/01/2019	ARCHIVED - Parsabiv
Pavblu (aflibercept-ayyh) (Commercial and QUEST)	No PA required
Pavblu (aflibercept-ayyh) (Medicare Advantage)	No PA required
PCSK9 Inhibitors Preferred Drug Program (Commercial)		11/21/2025		PCSK9 Inhibitors Preferred Drug Program	ARCHIVED - PCSK9 Inhibitors Preferred Drug Program
pemetrexed (generic)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Pemfexy (pemetrexed)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Pemrydi RTU (pemetrexed)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Pepaxto (melphalan flufenamide)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Perjeta (pertuzumab)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Phesgo pertuzumab, trastuzumab, hyaluronidase-zzxf)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Piasky (crovalimab-akkz)		06/12/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Plegridy (peginterferon beta-1a) (Multiple Sclerosis Preferred Program) (Commercial)		11/21/2025	Commercial Fax Form	Multiple Sclerosis (MS) - Interferons Preferred Drug Program	ARCHIVED - Multiple Sclerosis (MS) – Preferred Drug Program
plerixafor (generic) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Mozobil (plerixafor) (Commercial and QUEST)	ARCHIVED - Mozobil (Comm-QUEST)
Polivy (polatuzumab vedotin-piiq)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Portrazza (necitumumab)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Poteligeo (mogamulizumab-kpkc)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Praluent (alirocumab) PCSK9 Inhibitors Preferred Program (Commercial)		11/21/2025	Refer below for Praluent Fax Forms	PCSK9 Inhibitors Preferred Drug Program	ARCHIVED - PCSK9 Inhibitors Preferred Drug Program
2. Praluent (alirocumab) (Commercial and QUEST)		12/19/2025	Commercial Fax Form QUEST Fax Form		ARCHIVED - Praluent
Privigen (human immunoglobulin) (Commercial & QUEST)		07/25/2025	Commercial Fax Form QUEST Fax Form	Intravenous Immune Globulin (IVIG)	ARCHIVED - IVIG (Comm-QI)
Privigen (human immunoglobulin) (Medicare Advantage)		06/26/2026	Medicare Advantage Fax Form	Intravenous Immune Globulin (IVIG) - MA	ARCHIVED - IVIG (MA)
Probuphine				No PA required as of 09/01/2019
Procrit				No PA required as of 11/23/2015
Profilnine [Factor IX (plasma derived)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Prolastin-C (alpha1-proteinase inhibitor [human])		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Prolia (denosumab) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form		ARCHIVED - Prolia (Comm-QUEST) ARCHIVED - Prolia
Prolia (denosumab) (Medicare Advantage)	60-day provider notice 08/01/2026-09/30/2026, in effect 10/01/2026	06/27/2025	Medicare Advantage Fax Form	Prolia and Biosimilars (Medicare Advantage) Added eff 6/27/2025	ARCHIVED - Prolia (MA)
Provenge (sipuleucel-T)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Purified Cortrophin Gel (repository corticotropin injection)		12/19/2025	Fax Form	H.P. Acthar Gel Effective 9/1/2022	ARCHIVED - HP Acthar Gel (Comm-QUEST)
1. Pyzchiva (ustekinumab-ttwe) (Autoimmune Preferred Drug Program)		01/01/2026		Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Pyzchiva (ustekinumab-ttwe) (Commercial)		01/19/2026	Commercial Fax Form	Stelara and Biosimilars (Commercial) Added eff 4/8/2025	ARCHIVED - Stelara and Biosimilars (Commerical)
Pyzchiva (ustekinumab-ttwe) (QUEST)		01/19/2026	QUEST Fax Form	Stelara and Biosimilars (QUEST)	ARCHIVED - Stelara and Biosimilars (QUEST)
Pyzchiva (ustekinumab-ttwe) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Stelara and Biosimilars (Medicare Advantage)	ARCHIVED - Stelara (MA)

Q

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Qfitlia [Antithrombin Lowering Agent (fitusiran)]	Please contact HMSA at 808-948-6464, option #4, for drug review.
Qivigy (Medicare Advantage)		06/26/2026	Medicare Advantage Fax Form	Intravenous Immune Globulin (IVIG) - MA	ARCHIVED - IVIG (MA)

R

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Radicava (edaravone)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Rebif (interferon beta-1a) (Commercial)	No PA required	11/21/2025		Multiple Sclerosis (MS) - Interferons Preferred Drug Program	ARCHIVED - Multiple Sclerosis (MS) – Preferred Drug Program
Rebinyn [Factor IX (recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Recombinate [Factor VIII (recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Redemplo (plozasiran)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Added effective 12/23/2025	ARCHIVED - SDRP
Releuko (filgrastim-ayow) (CSF Short Acting Preferred Drug Program Commercial and QUEST)		11/21/2025	Commercial Fax Form QUEST Fax Form	Colony Stimulating Factors (CSF) – Short Acting Preferred Drug Program	ARCHIVED - CSF Short Acting Preferred Drug Program
Releuko (filgrastim-ayow) (CSF Short Acting Preferred Drug Program Medicare Advantage)		11/21/2025	Medicare Advantage Fax Form	Colony Stimulating Factors (CSF) –Short Acting Preferred Drug Program MA Effective 1/1/2024	ARCHIVED - CSF Short Acting (Preferred Drug Program) (MA)
1. Remicade (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Remicade Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Remicade (infliximab) (Commercial)		07/01/2026	Commercial Fax Form	Infliximab-Avsola-Inflectra-Remicade-Renflexis-Zymfentra	ARCHIVED - Infliximab (Comm-QUEST) ARCHIVED - Infliximab
Remicade (infliximab) (QUEST)		07/01/2026	QUEST Fax Form	Infliximab-Avsola-Inflectra-Renflexis-Zymfentra (QUEST)	ARCHIVED - Infliximab (QUEST)
Remicade (infliximab) (Medicare Advantage)		12/19/2025	Medicare Advantage Fax Form	Infliximab-Avsola-Inflectra-Remicade-Renflexis MA	ARCHIVED - Infliximab (MA)
Remodulin (treprostinil) (Commercial and QUEST)		06/01/2026	Fax Form		ARCHIVED - Remodulin (Comm-QUEST) ARCHIVED - Remodulin
Remodulin (treprostinil) (Medicare Advantage)		11/21/2025	Medicare Advantage Fax Form		ARCHIVED - Remodulin (MA)
1. Renflexis (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Renflexis Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Renflexis (infliximab-abda) (Commercial)		04/01/2026	Commercial Fax Form	Infliximab-Avsola-Inflectra-Remicade-Renflexis-Zymfentra	ARCHIVED - Infliximab (Comm-QUEST) ARCHIVED - Infliximab
Renflexis (infliximab-abda) (QUEST)		07/01/2026	QUEST Fax Form	Infliximab-Avsola-Inflectra-Renflexis-Zymfentra (QUEST)	ARCHIVED - Infliximab (QUEST)
Renflexis (infliximab-abda) (Medicare Advantage)		12/19/2025		Infliximab-Avsola-Inflectra-Remicade-Renflexis MA	ARCHIVED - Infliximab (MA)
1. Repatha (evolocumab) PCSK9 Inhibitors Preferred Program (Commercial)		11/21/2025		PCSK9 Inhibitors Preferred Drug Program	ARCHIVED - PCSK9 Inhibitors Preferred Drug Program
2. Repatha (evolocumab) (Commercial and QUEST)		12/19/2025	Fax Form		ARCHIVED - Repatha
Retinal Disorders Preferred Drug Program (Commercial)	No PA required				ARCHIVED - Retinal Disorders Preferred Drug Program (Commercial)
Retinal Disorders Preferred Drug Program (Medicare Advantage)	No PA required as of 01/01/2024			Retinal Disorders Preferred Drug Program	ARCHIVED - Retinal Disorders Preferred Drug Program (MA)
Revatio (sildenafil)	No PA required as of 01/01/2024				ARCHIVED - Revatio
Revcovi (elapegademase-ivir)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
1. Riabni (rituximab-arrx) (Rituximab Preferred Drug Program Commercial)		01/01/2026	Commercial Fax Form	Rituximab Products - Preferred Drug Program Commercial Effective 1/1/2024	ARCHIVED - Rituximab Products (Commercial)
2. Riabni (rituximab-arrx) (Commercial)		06/12/2026		Global Oncology	ARCHIVED - Global Oncology
1. Riabni (rituximab-arrx) (Rituximab Preferred Drug Program Medicare Advantage)		01/01/2026	Medicare Advantage Fax Form	Rituximab Products - Preferred Drug Program MA Effective 1/1/2024	ARCHIVED - Rituximab Products (MA)
2. Riabni (rituximab-arrx) (Medicare Advantage)		06/12/2026		Global Oncology	ARCHIVED - Global Oncology
Riabni (rituximab-arrx) (QUEST)		06/12/2026	QUEST Fax Form	Global Oncology	ARCHIVED - Global Oncology
Riabni (rituximab-arrx) (Non-oncology) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Rituximab-Riabni-Rituxan-Ruxience-Truxima	ARCHIVED - Rituximab (non-oncology) (Comm-QI) ARCHIVED - Rituximab
Riabni (rituximab-arrx) (Non-oncology) (Medicare Advantage)		12/19/2025		Rituximab-Riabni-Rituxan-Ruxience-Truxima MA	ARCHIVED - Rituximab (non-oncology) (MA)
1. Rituxan (rituximab) (Rituximab Preferred Drug Program Commercial)		01/01/2026	Commercial Fax Form	Rituximab Products - Preferred Drug Program Commercial Effective 1/1/2024	ARCHIVED - Rituximab Products (Commercial)
2. Rituxan (rituximab) (Oncology) (Commercial)		06/12/2026		Global Oncology	ARCHIVED - Global Oncology
1. Rituxan (rituximab) (Rituximab Preferred Drug Program Medicare Advantage)		01/01/2026	Medicare Advantage Fax Form	Rituximab Products - Preferred Drug Program MA Effective 1/1/2024	ARCHIVED - Rituximab Products (MA)
2. Rituxan (rituximab) (Oncology) (Medicare Advantage)		06/12/2026		Global Oncology	ARCHIVED - Global Oncology
Rituxan (rituximab) (QUEST)		06/12/2026	QUEST Fax Form	Global Oncology	ARCHIVED - Global Oncology
Rituxan (rituximab) (Non-oncology) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Rituximab-Riabni-Rituxan-Ruxience-Truxima	ARCHIVED - Rituximab (non-oncology) (Comm-QI) ARCHIVED - Rituximab
Rituxan (rituximab) (Non-oncology) (Medicare Advantage)		12/19/2025		Rituximab-Riabni-Rituxan-Ruxience-Truxima MA	ARCHIVED - Rituximab (non-oncology) (MA)
1. Rituxan Hycela (rituximab and hyaluronidase human) (Rituximab Preferred Drug Program Commercial)		01/01/2026	Commercial Fax Form	Rituximab Products - Preferred Drug Program Commercial Effective 1/1/2024	ARCHIVED - Rituximab Products (Commercial)
2. Rituxan Hycela (rituximab and hyaluronidase human) (Commercial)		06/12/2026	Commercial Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Rituxan Hycela (rituximab and hyaluronidase human) (Rituximab Preferred Drug Program Medicare Advantage)		01/01/2026	Medicare Advantage Fax Form	Rituximab Products - Preferred Drug Program MA Effective 1/1/2024	ARCHIVED - Rituximab Products (MA)
2. Rituxan Hycela (rituximab and hyaluronidase human) (Medicare Advantage)		06/12/2026	Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Rituxan Hycela (rituximab and hyaluronidase human (QUEST)		06/12/2026	Fax Form	Global Oncology	ARCHIVED - Global Oncology
Rituximab Preferred Drug Program (Commercial)		01/01/2026	Commercial Fax Form	Rituximab Products - Preferred Drug Program Commercial	ARCHIVED - Rituximab Products (Commercial)
Rituximab (non-oncology) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Rituximab-Riabni-Rituxan-Ruxience-Truxima	ARCHIVED - Rituximab (non-oncology) (Comm-QI) ARCHIVED - Rituximab
1. Rituximab Preferred Drug Program (Medicare Advantage)		01/01/2026		Rituximab Products - Preferred Drug Program MA	ARCHIVED - Rituximab Products (MA)
2. Rituximab (non-oncology) (Medicare Advantage)		12/19/2025	Medicare Advantage Fax Form	Rituximab-Riabni-Rituxan-Ruxience-Truxima MA	ARCHIVED - Rituximab (non-oncology) (MA)
Rivfloza (nedosiran)		06/12/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) eff 1/1/2024	ARCHIVED - SDRP
Rixubis [Factor IX (recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Roctavian (valoctocogene roxaparvovec-rvox)	Please contact HMSA at 808-948-6464, option #4, for drug review
Rolvedon (eflapegrastimxnst) (Commercial)		01/01/2026	Commercial Fax Form	Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program	ARCHIVED - CSF Long Acting Preferred Drug Program
Rolvedon (eflapegrastimxnst) (Medicare Advantage)		01/01/2026	Medicare Advantage Fax Form	Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program	ARCHIVED - CFS Long Acting Preferred Drug Program (MA)
romidepsin		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Ruconest (C1 esterase inhibitor [recombinant]) (Hereditary Angioedema Preferred Drug Program) (Commercial)		11/21/2025	Refer below for Ruconest Fax Forms	Hereditary Angioedema Preferred Drug Program	ARCHIVED - Hereditary Angioedema Preferred Drug Program
2. Ruconest (recombinant C1 esterase inhibitor) (Commercial and QUEST)		01/01/2026	Fax Form		ARCHIVED - Ruconest (Comm-QUEST) ARCHIVED - Ruconest
Ruconest (recombinant C1 esterase inhibitor) (Medicare Advantage)		01/01/2026	Medicare Advantage Fax Form		ARCHIVED - Ruconest (MA)
1. Ruxience (rituximab-pvvr) (Rituximab Preferred Drug Program Commercial)		01/01/2026	Commercial Fax Form	Rituximab Products - Preferred Drug Program Commercial Effective 1/1/2024	ARCHIVED - Rituximab Products (Commercial)
2. Ruxience (rituximab-pvvr) (oncology) (Commercial)		06/12/2026		Global Oncology	ARCHIVED - Global Oncology
1. Ruxience (rituximab-pvvr) (Rituximab Preferred Drug Program Medicare Advantage)		01/01/2026	Medicare Advantage Fax Form	Rituximab Products - Preferred Drug Program MA Effective 1/1/2024	ARCHIVED - Rituximab Products (MA)
2. Ruxience (rituximab-pvvr) (oncology) (Medicare Advantage)		06/12/2026		Global Oncology	ARCHIVED - Global Oncology
Ruxience (rituximab-pvvr) (oncology) (QUEST)		06/12/2026	QUEST Fax Form	Global Oncology	ARCHIVED - Global Oncology
Ruxience (rituximab-pvvr) (Non-oncology) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Rituximab-Riabni-Rituxan-Ruxience-Truxima	ARCHIVED - Rituximab (non-oncology) (Comm-QI) ARCHIVED - Rituximab
Ruxience (rituximab-pvvr) (Non-oncology) (Medicare Advantage)		12/19/2025		Rituximab-Riabni-Rituxan-Ruxience-Truxima MA	ARCHIVED - Rituximab (non-oncology) (MA)
Rybrevant (amivantamab-vmjw)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Rybrevant Faspro (amivantamab and hyaluronidase-lpuj)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Added effective 3/13/2026	ARCHIVED - Global Oncology
Rylaze (asparaginase erwinia chrysanthemi (recombinant) -rywn)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Ryoncil (remestemcel-L-rknd)		06/12/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) added eff 03/01/2025	ARCHIVED - SDRP
Ryplazim (plasminogen, human-tvmh)		06/12/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) eff 4/1/2022	ARCHIVED - SDRP
Rystiggo (rozanolixizumab-noli)		06/12/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) eff 7/1/2023	ARCHIVED - SDRP
Rytelo (imetelstat sodium)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Ryzneuta (efbemalenograstim alfa-vuxw)		06/12/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Added effective 07/01/2025	ARCHIVED - SDRP

S

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Saizen® (somatropin) (Commercial and QUEST)		01/01/2026	Fax Form	Growth Hormone	ARCHIVED - Growth Hormone
sajazir (icatibant) (Commercial and QUEST)		01/01/2026	Commercial Fax Form QUEST Fax Form	icatibant–Firazir-sajazir	ARCHIVED - Icatibant (Comm-QUEST)
Saphnelo (anifrolumab-fnia)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) (effective 12/10/2021)	ARCHIVED - SDRP
Sarclisa (isatuximab-irfc)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Scenesse (afamelanotide)	No PA required as of 1/1/2024				ARCHIVED - Scenesse
1. Selarsdi (ustekinumab-aekn) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026		Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Selarsdi (ustekinumab-aekn) (Commercial)		01/19/2026	Commercial Fax Form	Stelara and Biosimilars (Commercial) Added eff 4/8/2025	ARCHIVED - Stelara and Biosimilars (Commercial)
Selarsdi (ustekinumab-aekn) (QUEST)		01/19/2026	QUEST Fax Form	Stelara and Biosimilars (QUEST)	ARCHIVED - Stelara and Biosimilars (QUEST)
Selarsdi (ustekinumab-aekn) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Stelara and Biosimilars (Medicare Advantage)	ARCHIVED - Stelara (MA)
Serostim (somatropin) (Commercial and QUEST)		01/01/2026	Fax Form	Growth Hormone	ARCHIVED - Growth Hormone
Sevenfact [Factor VIIA (recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review
Signifor (pasireotide)		09/26/2025	Fax Form		ARCHIVED - Signifor (Comm-QUEST)
Signifor LAR (pasireotide long acting)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
1. Siliq (brodalumab) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Siliq Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Siliq (brodalumab) (Commercial and QUEST)		10/27/2025	Commerical Fax Form QUEST Fax Form	Specific drug criteria for Siliq eff 10/1/2020	ARCHIVED - Siliq
1. Simlandi (adalimumab-ryvk) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026		Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Simlandi (adalimumab-ryvk) (Commercial)		05/25/2025	Commercial Fax Form	Humira (adalimumab) Effective 7/1/2024	ARCHIVED - Adalimumab (Humira)
Simlandi (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QI)
1. Simponi (golimumab for subcutaneous injection) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Simponi Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2 Simponi (golimumab for subcutaneous injection) (Commercial and QUEST)		05/25/2025	Fax Form	Specific drug criteria for Simponi	ARCHIVED - Simponi
1. Simponi Aria (golimumab for subcutaneous injection) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Simponi Aria Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2 Simponi Aria (golimumab injection for intravenous use) (Commercial and QUEST)		05/25/2025	Fax Form QUEST Fax Form	Specific drug criteria for Simponi Aria	ARCHIVED - Simponi Aria (COMM-QI) ARCHIVED - Simponi Aria
Simponi Aria (golimumab injection for intravenous use) (Medicare Advantage)		03/27/2026	Medicare Advantage Fax Form		ARCHIVED - Simponi Aria (MA)
1. Skyrizi (risankizumab-rzaa) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Skyrizi Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Skyrizi (risankizumab-rzaa) (Commercial and QUEST)		12/19/2025	Commercial Fax Form QUEST Fax Form	Specific drug criteria for Skyrizi	ARCHIVED - Skyrizi
Skyrizi IV (risankizumab-rzaa) (Medicare Advantage)		06/01/2026			ARCHIVED - Skyrizi IV
Skysona (elivaldogene autotemcel)	Please contact HMSA at 808-948-6464, option #4, for drug review
Skytrofa (lonapegsomatropin-tcgd)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Effective 12/10/2021	ARCHIVED - SDRP
Sogroya somapacitan-beco)		06/12/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Effective 5/1/2023	ARCHIVED - SDRP
Soliris (eculizumab) (Commercial and QUEST)		12/19/2025	Fax Form		ARCHIVED - Soliris (Comm-QUEST) ARCHIVED - Soliris
Soliris (eculizumab) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Soliris-Bkemy-Epysqli	ARCHIVED - Soliris (MA)
Somatuline Depot (lanreotide) (Non-oncology) (Commercial and QUEST)		09/26/2025	Fax Form	Somatuline Depot-Lanreotide	ARCHIVED - Lanreotide (Comm-QI) ARCHIVED - Somatuline Depot
Somatuline Depot (lanreotide) (Non-oncology) (Medicare Advantage)		10/27/2025	Medicare Advantage Fax Form	Somatuline Depot-Lanreotide MA	ARCHIVED - Lanreotide (MA)
Specialty Drugs Requiring Precertification (SDRP)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Spevigo (spesolimab-sbzo)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Effective 11/1/2022	ARCHIVED - SDRP
Spinraza (nusinersen) (Commercial and QUEST)		09/26/2025	Commercial Fax Form QUEST Fax Form		ARCHIVED - Spinraza (Comm-QUEST) ARCHIVED - Spinraza
Spinraza (nusinersen) (Medicare Advantage)		09/26/2025	Medicare Advantage Fax Form		ARCHIVED - Spinraza (MA)
Spravato (esketamine) This policy can be accessed from the HMSA Medical Policies - CURRENT article under Intranasal Esketamine for Major Depressive Disorder with Acute Suicidality and Treatment-Resistant Depression	Please contact HMSA at 808-948-6464, option #4, for drug review
1. Starjemza (ustekinumab-hmny) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026			ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Starjemza (ustekinumab-hmny) (Commercial)		01/19/2026	Commercial Fax Form	Stelara and Biosimilars (Commercial) Added eff 4/8/2025	ARCHIVED - Stelara and Biosimilars (Commercial)
Starjemza (ustekinumab-hmny) (QUEST)		01/19/2026	QUEST Fax Form	Stelara and Biosimilars (QUEST)	ARCHIVED - Stelara and Biosimilars (QUEST)
Starjemza (ustekinumab-hmny) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Stelara and Biosimilars (Medicare Advantage)	ARCHIVED - Stelara (MA)
1. Stelara (ustekinumab) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Stelara Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Stelara (ustekinumab) (Commercial)		01/19/2026	Commercial Fax Form	Stelara (Commercial) Added Biosimilars effective 4/8/2025	ARCHIVED - Stelara and Biosimilars (Commercial) ARCHIVED - Stelara
Stelara (ustekinumab) (QUEST)		01/19/2026	QUEST Fax Form	Stelara and Biosimilars (QUEST)	ARCHIVED - Stelara and Biosimilars (QUEST)
Stelara (ustekinumab) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Stelara and Biosimilars (Medicare Advantage)	ARCHIVED - Stelara (MA)
1. Steqeyma (ustekinumab-stba) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026		Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Steqeyma (ustekinumab-stba) (Commercial)		01/19/2026	Commercial Fax Form	Stelara and Biosimilars (Commercial) Added eff 4/8/2025	ARCHIVED - Stelara and Biosimilars (Commercial)
Steqeyma (ustekinumab-stba) (QUEST)		01/19/2026	QUEST Fax Form	Stelara and Biosimilars (QUEST)	ARCHIVED - Stelara and Biosimilars (QUEST)
Steqeyma (ustekinumab-stba) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Stelara and Biosimilars (Medicare Advantage)	ARCHIVED - Stelara (MA)
Strensiq (asfotase alfa)		06/12/2026	Fax Form	Specialty Drugs Requiring Precertification (SDRP) Drug is not covered under Part B	ARCHIVED - SDRP
Stimufend (pegfilgrastim-fpgk) (Commercial)		01/01/2026	Commercial Fax Form	Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program	ARCHIVED - CSF Long Acting Preferred Drug Program
Stimufend (pegfilgrastim-fpgk) (Medicare Advantage)		01/01/2026	Medicare Advantage Fax Form	Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program	ARCHIVED - CFS Long Acting Preferred Drug Program (MA)
Stoboclo (denosumab-bmwo) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Prolia and Biosimilars (Commercial and QUEST) Added eff 10/01/2025	ARCHIVED - Prolia (Comm-QUEST)
Stoboclo (denosumab-bmwo) (Medicare Advantage)	60-day provider notice 08/01/2026-09/30/2026, in effect 10/01/2026	06/27/2025	Medicare Advantage Fax Form	Prolia and Biosimilars (Medicare Advantage) Added eff 6/27/2025	ARCHIVED - Prolia (MA)
Sublocade (buprenorphine)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
1. Supartz FX® (Hyaluronates Preferred Drug Program) (Commercial and QUEST)		01/01/2026	See below for Supartz FX® Commercial Fax Form	Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (Commercial)
2. Supartz FX® (sodium hyaluronate) (Commercial and QUEST)		06/26/2026	Commercial Fax Form QUEST Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QI) ARCHIVED - Hyaluronates (drug specific)
1. Supartz FX® (Hyaluronates Preferred Drug Program) (Medicare Advantage)		01/01/2026	See below for Supartz FX® Commercial Fax Form	Hyaluronates Preferred Drug Program MA	ARCHIVED - Hyaluronates Preferred Drug Program (MA)
2. Supartz FX® (sodium hyaluronate) (Medicare Advantage)		03/13/2026	Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)
Supprelin LA (histrelin acetate implant)		01/01/2026	Fax Form		ARCHIVED - Supprelin LA
Syfovre (pegcetacoplan)		06/12/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Added to policy on 3/6/2023	ARCHIVED - SDRP
Sylvant (siltuximab)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Synagis (palivizumab				Discontinued by manufacturer effective 12/31/2025	ARCHIVED - Synagis
Synribo (omacetaxine mepesuccinate)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Synojoynt (1% sodium hyaluronate) (Commercial and QUEST)		06/26/2026	Commercial Fax Form QUEST Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QI)
Synojoynt (1% sodium hyaluronate) (Medicare Advantage)		03/13/2026	Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA)
1. Synvisc® (Hyaluronates Preferred Drug Program) (Commercial and QUEST)		01/01/2026	See below for Synvisc Commercial Fax Form	Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (Commercial)
2. Synvisc® (hylan G-F 20) (Commercial and QUEST)		06/26/2026	Commercial Fax Form QUEST Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QI) ARCHIVED - Hyaluronates (drug specific)
1. Synvisc (Hyaluronates Preferred Drug Program) (Medicare Advantage)		01/01/2026	See below for Synvisc Medicare Advantage Fax Form	Hyaluronates Preferred Drug Program MA	ARCHIVED - Hyaluronates Preferred Drug Program (MA)
2. Synvisc® (hylan G-F 20) (Medicare Advantage)		03/13/2026	Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)
1. Synvisc One® (Hyaluronates Preferred Drug Program) (Commercial and QUEST)		01/01/2026	See below for Synvisc One Commercial Fax Form	Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (Commercial)
2. Synvisc One® (hylan G-F 20) (Commercial and QUEST)		06/26/2026	Commercial Fax Form QUEST Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QI) ARCHIVED - Hyaluronates (drug specific)
1. Synvisc One® (Hyaluronates Preferred Drug Program) (Medicare Advantage)		01/01/2026	See below for Synvisc One Medicare Advantage Fax Form	Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (MA)
2. Synvisc One® (hylan G-F 20) (Medicare Advantage)		03/13/2026	Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)

T

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Takhzyro (lanadelumab-flyo)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
1. Taltz (ixekizumab) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Taltz Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Taltz (ixekizumab) (Commercial and QUEST)		12/19/2025	Commercial Fax Form QUEST Fax Form	Specific drug criteria for 11/18/2025Taltz eff 10/1/2020	ARCHIVED - Taltz
Talvey (talquetamab-tgvs)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Effective 9/5/2023	ARCHIVED - Global Oncology
Tecartus (brexucabtagene autoleucel)	Effective 07/31/2020: Please contact HMSA at 808-948-6464, option #4, for drug review
Tecentriq (atezolizumab)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Tecvayli (teclistamab-cqyv)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Tegsedi (inotersen)	Effective 9/27/2024 Tegsedi is discontinued.			Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
temsirolimus (generic)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Tepezza (teprotumumab-trbw)		09/26/2025	Commercial Fax Form QUEST Fax Form	Drug specific Effective 1/1/2025 Specialty Drugs Requiring Precertification (SDRP) Effective 1/1/25: Removed from SDRP policy	ARCHIVED - Tepezza (Comm-QUEST) ARCHIVED - SDRP
Tepylute (thiotepa)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
teriparatide (generic)		06/27/2025	Fax Form	Forteo (teriparatide) Effective 4/1/2023	ARCHIVED - Forteo
Tevimbra (tislelizumab-jsgr)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global OncologyEffective 9/10/2024	ARCHIVED - Global Oncology
Tezspire (tezepelumab-ekko)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Added effective 4/1/2022	ARCHIVED - SDRP
Tivdak (tisotumab vedotin-tftv)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Tofidence (tocilizumab-bavi) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026		Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Tofidence (tocilizumab-bavi)(Commercial)		04/01/2026	Commercial Fax Form	Actemra-Avtozma-Tofidence-Tyenne	ARCHIVED - Actemra (COMM-QI)
Tofidence (tocilizumab-bavi)(QUEST)		04/01/2026		Actemra-Avtozma-Tofidence-Tyenne	ARCHIVED - Actemra (COMM-QI)
Tofidence (tocilizumab-bavi) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Actemra-Avtozma-Tofidence-Tyenne	ARCHIVED - Actemra (MA)
Torisel (temsirolimus)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Trastuzumab Preferred Drug Program (Commercial and QUEST)		01/01/2026		Trastuzumab Products - Preferred Drug Program Commercial Effective 1/1/2024	ARCHIVED - Trastuzumab Products (Commercial)
Trastuzumab Preferred Drug Program (Medicare Advantage)		01/01/2026		Trastuzumab Products - Preferred Drug Program MA Effective 1/1/2024	ARCHIVED - Trastuzumab Products (MA)
1. Trazimera (trastuzumab-qyyp) (Trastuzumab Preferred Drug Program Commercial and QUEST)		01/01/2026	Refer below for Trazimera fax forms	Trastuzumab Products - Preferred Drug Program Commercial Effective 1/1/2024	ARCHIVED - Trastuzumab Products (Commercial)
2. Trazimera (trastuzumab-qyyp) (Commercial and QUEST)		06/12/2026	Commercial Fax Form QUEST Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Trazimera (trastuzumab-qyyp) (Trastuzumab Preferred Drug Program Medicare Advantage)		01/01/2026	Refer below for Trazimera fax forms	Trastuzumab Products - Preferred Drug Program MA Effective 1/1/2024	ARCHIVED - Trastuzumab Products (MA)
2. Trazimera (trastuzumab-qyyp) (Medicare Advantage)		06/12/2026	Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Tremfya (guselkumab) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Tremfya Fax Forms	Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Tremfya (guselkumab) (Commerical and QUEST)		02/23/2026	Commercial Fax Form QUEST Fax Form	Specific drug criteria for Tremfya eff 10/1/2020	ARCHIVED - Tremfya (Comm-QUEST)
Tremfya IV (guselkumab) (Medicare Advantage)		10/01/2025			ARCHIVED - Tremfya IV (MA)
treprostinil (generic) (Commercial and QUEST)		06/01/2026	Fax Form	Remodulin	ARCHIVED - Remodulin (Comm-QUEST) ARCHIVED - Remodulin
treprostinil (generic) (Medicare Advantage)		11/21/2025	Medicare Advantage Fax Form	Remodulin	ARCHIVED - Remodulin (MA)
1. Triluron (sodium hyaluronate) (Hyaluronates Preferred Drug Program) (Commercial and QUEST)		01/01/2026	See below for Triluron Commercial Fax Form	Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (Commercial)
2. Triluron (sodium hyaluronate) (Commercial and QUEST)		06/26/2026	Commercial Fax Form QUEST Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QI) ARCHIVED - Hyaluronates (drug specific)
1. Triluron (sodium hyaluronate) (Hyaluronates Preferred Drug Program) (Medicare Advantage)		01/01/2026	See below for Triluron Commercial Fax Form	Hyaluronates Preferred Drug Program MA	ARCHIVED - Hyaluronates Preferred Drug Program (MA)
2. Triluron (sodium hyaluronate) (Medicare Advantage)		03/13/2026	Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)
Triptodur (triptorelin pamoate)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Trisenox (arsenic trioxide)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Trivisc® (Hyaluronates Preferred Drug Program) (Commercial and QUEST)		01/01/2026	See below for Trivisc Commercial Fax Form	Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (Commercial)
2. Trivisc® (sodium hyaluronate) (Commercial and QUEST)		06/26/2026	Commercial Fax Form QUEST Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QI) ARCHIVED - Hyaluronates (drug specific)
1. Trivisc® (Hyaluronates Preferred Drug Program) (Medicare Advantage)		01/01/2026	See below for Trivisc Medicare Advantage Fax Form	Hyaluronates Preferred Drug Program MA	ARCHIVED - Hyaluronates Preferred Drug Program (MA)
2. Trivisc® (sodium hyaluronate) (Medicare Advantage)		03/13/2026	Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)
Trodelvy (sacituzumab govitecan-hziy)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Truxima (rituximab-abbs) (Rituximab Preferred Drug Program Commercial)		01/01/2026	Commercial Fax Form	Rituximab Products - Preferred Drug Program Commercial Effective 1/1/2024	ARCHIVED - Rituximab Products (Commercial)
2. Truxima (rituximab-abbs) (Commercial)		06/12/2026		Global Oncology	ARCHIVED - Global Oncology
1. Truxima (rituximab-abbs) (Rituximab Preferred Drug Program Medicare Advantage)		01/01/2026	Medicare Advantage Fax Form	Rituximab Products - Preferred Drug Program MA Effective 1/1/2024	ARCHIVED - Rituximab Products (MA)
2. Truxima (rituximab-abbs) (Medicare Advantage)		06/12/2026		Global Oncology	ARCHIVED - Global Oncology
Truxima (rituximab-abbs) (QUEST)		06/12/2026	QUEST Fax Form	Global Oncology	ARCHIVED - Global Oncology
Truxima (rituximab-abbs) (Non-oncology) (Commercial and QUEST)		04/01/2026	Commercial Fax Form QUEST Fax Form	Rituximab-Rituxan-Ruxience-Truxima	ARCHIVED - Rituximab (non-oncology) (Comm-QI) ARCHIVED - Rituximab
Truxima (rituximab-abbs) (Non-oncology) (Medicare Advantage)		12/19/2025		Rituximab-Rituxan-Ruxience-Truxima MA	ARCHIVED - Rituximab (non-oncology) (MA)
Tryngolza (olezarsen sodium)		06/12/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
1. Tyenne (tocilizumab-aazg) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026		Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Tyenne (tocilizumab-aazg) (Commercial)		04/01/2026	Commercial Fax Form	Actemra-Avtozma-Tofidence-Tyenne	ARCHIVED - Actemra (COMM-QI)
Tyenne (tocilizumab-aazg) (QUEST)		04/01/2026	Commercial Fax Form	Actemra-Avtozma-Tofidence-Tyenne	ARCHIVED - Actemra (COMM-QI)
Tyenne (tocilizumab-aazg) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Actemra-Avtozma-Tofidence-Tyenne	ARCHIVED - Actemra (MA)
Tymlos (abaloparatide)		06/27/2025	Commercial Fax Form QUEST Fax Form	Effective 4/1/23: Drug specific policy Effective 4/1/23: Removed from SDRP policy. Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - Tymlos ARCHIVED - SDRP Refer to policies eff 3/1/2023 and earlier
Tzield (teplizumab-mzwv)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Effective 12/1/2022	ARCHIVED - SDRP

U

Policy Name	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Udenyca (pegfilgrastim-cbqv) (Commercial)	01/01/2026	Commercial Fax Form	Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program	ARCHIVED - CSF Long Acting Preferred Drug Program
Udenyca (pegfilgrastim-cbqv) (Medicare Advantage)	01/01/2026	Medicare Advantage Fax Form	Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program	ARCHIVED - CFS Long Acting Preferred Drug Program (MA)
Ultomiris (ravulizumab-cwvz)	06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Unituxin (dinutuximab)	06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Unloxcyt (cosibelimab-ipdl)	06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Uplizna (ineblizumab-cdon)	06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
ustekinumab (unbranded Stelara) (Commercial)	01/19/2026	Commercial Fax Form	Stelara and Biosimilars (Commercial) Added effective 01/19/2026	ARCHIVED - Stelara and Biosimilars (Commercial)
Ustekinumab (Stelara and Biosimilars) (QUEST)	01/19/2026	QUEST Fax Form	Stelara and Biosimilars (QUEST)	ARCHIVED - Stelara and Biosimilars (QUEST)
ustekinumab (unbranded Stelara) (Medicare Advantage)	04/01/2026	Medicare Advantage Fax Form	Stelara and Biosimilars (Medicare Advantage)	ARCHIVED - Stelara (MA)
ustekinumab-aauz (unbranded Otulfi) (Commercial)	01/19/2026	Commercial Fax Form	Stelara and Biosimilars (Commercial) Added effective 01/19/2026	ARCHIVED - Stelara and Biosimilars (Commercial)
ustekinumab-aauz (unbranded Otulfi) (QUEST)	01/19/2026	QUEST Fax Form	Stelara and Biosimilars (QUEST)	ARCHIVED - Stelara and Biosimilars (QUEST)
ustekinumab-aauz (unbranded Otulfi) (Medicare Advantage)	04/01/2026	Medicare Advantage Fax Form	Stelara and Biosimilars (Medicare Advantage)	ARCHIVED - Stelara (MA)
1. ustekinumab-aekn (unbranded Selarsdi) (Autoimmune Preferred Drug Program) (Commercial)	01/01/2026		Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. ustekinumab-aekn (unbranded Selarsdi) (Commercial)	01/19/2026	Commercial Fax Form	Stelara and Biosimilars (Commercial) Added eff 4/8/2025	ARCHIVED - Stelara and Biosimilars (Commercial)
ustekinumab-aekn (unbranded Selarsdi) (QUEST)	01/19/2026	QUEST Fax Form	Stelara and Biosimilars (QUEST)	ARCHIVED - Stelara and Biosimilars (QUEST)
ustekinumab-aekn (unbranded Selarsdi)(Medicare Advantage)	04/01/2026	Medicare Advantage Fax Form	Stelara and Biosimilars (Medicare Advantage)	ARCHIVED - Stelara (MA)
ustekinumab-JJ (Autoimmune Preferred Drug Program) (Commercial)	01/01/2026			ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
ustekinumab-stba (unbranded Steqeyma) (Commercial)	01/19/2026	Commercial Fax Form	Stelara and Biosimilars (Commercial) Added effective 01/19/2026	ARCHIVED - Stelara and Biosimilars (Commercial)
ustekinumab-stba (unbranded Steqeyma) (QUEST)	01/19/2026	QUEST Fax Form	Stelara and Biosimilars (QUEST)	ARCHIVED - Stelara and Biosimilars (QUEST)
ustekinumab-stba (unbranded Steqeyma) (Medicare Advantage)	04/01/2026	Medicare Advantage Fax Form	Stelara and Biosimilars (Medicare Advantage)	ARCHIVED - Stelara (MA)
1. ustekinumab-ttwe (unbranded Pyzchiva) (Autoimmune Preferred Drug Program) (Commercial)	01/01/2026		Commercial plan members refer to the Preferred Drug Program policy first	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. ustekinumab-ttwe (unbranded Pyzchiva) (Commercial)	01/19/2026	Commercial Fax Form	Stelara and Biosimilars (Commercial) Added eff 4/8/2025	ARCHIVED - Stelara and Biosimilars (Commercial)
ustekinumab-ttwe (unbranded Pyzchiva) (QUEST)	01/19/2026	QUEST Fax Form	Stelara and Biosimilars (QUEST)	ARCHIVED - Stelara and Biosimilars (QUEST)
ustekinumab-ttwe (unbranded Pyzchiva) (Medicare Advantage)	04/01/2026	Medicare Advantage Fax Form	Stelara and Biosimilars (Medicare Advantage)	ARCHIVED - Stelara (MA)

V

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Vabysmo (faricimab-svoa)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) eff 4/1/2022	ARCHIVED - SDRP
Vectibix (Panitumumab)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Vegzelma (bevacizumab-adcd) (Bevacizumab Preferred Drug Program Commercial)		01/01/2026		Bevacizumab Products - Preferred Drug Program Commercial Effective 1/1/2024	ARCHIVED - Bevacizumab Products (Commercial)
2. Vegzelma (bevacizumab-adcd) (Commercial)		06/12/2026	Commercial Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Vegzelma (bevacizumab-adcd) (Bevacizumab Preferred Drug Program Medicare Advantage)		01/01/2026		Bevacizumab Products - Preferred Drug Program MA Effective 1/1/2024	ARCHIVED - Bevacizumab Products (MA)
2. Vegzelma (bevacizumab-adcd) (Medicare Advantage)		06/12/2026	Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Vegzelma (bevacizumab-adcd) (Bevacizumab Preferred Drug Program policy QUEST)		01/01/2026		Bevacizumab Products - Preferred Drug Program QUEST Effective 1/1/2025	ARCHIVED - Bevacizumab Products (QUEST)
2. Vegzelma (bevacizumab-adcd) (QUEST)		06/12/2026	QUEST Fax Form	Global Oncology	ARCHIVED - Global Oncology
Velcade (bortezomib)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Veletri (epoprostenol) (Commercial and QUEST)		06/01/2026	Fax Form	Flolan; Veletri; epoprostenol (generic)	ARCHIVED - Flolan-Veletri-epoprostenol (Comm-QI) ARCHIVED - Flolan-Veletr
Veletri (epoprostenol) (Medicare Advantage)		12/19/2025	Medicare Advantage Fax Form	Flolan; Veletri; epoprostenol (generic)	ARCHIVED - Flolan-Veletri-epoprostenol (MA)
Veopoz (pozelimab-bbfg)		06/12/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Effective 9/1/2023	ARCHIVED - SDRP
Viltepso (viltolarsen)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Vimizim (elosulfase alfa) (Commercial and QUEST)		05/23/2025	Fax Form		ARCHIVED - Vimzim (Comm-QI) ARCHIVED - Vimizim
Vimizim (elosulfase alfa) (Medicare Advantage)		06/26/2026	Medicare Advantage Fax Form		ARCHIVED - Vimzim (MA)
1. Visco-3 ® (Hyaluronates Preferred Drug Program) (Commercial and QUEST)		01/01/2026	See below for Visco-3 Commercial Fax Form	Hyaluronates Preferred Drug Program	ARCHIVED - Hyaluronates Preferred Drug Program (Commercial)
2. Visco-3 ® (sodium hyaluronate) (Commercial and QUEST)		06/26/2026	Commercial Fax Form QUEST Fax Form	Hyaluronates	ARCHIVED - Hyaluronates (Comm-QI) ARCHIVED - Hyaluronates (drug specific)
1. Visco-3 (Hyaluronates Preferred Drug Program) (Medicare Advantage)		01/01/2026	See below for Visco-3 Medicare Advantage Fax Form	Hyaluronates Preferred Drug Program MA	ARCHIVED - Hyaluronates Preferred Drug Program (MA)
2. Visco-3 ® (sodium hyaluronate) (Medicare Advantage)		03/13/2026	Medicare Advantage Fax Form	Hyaluronates MA	ARCHIVED - Hyaluronates (MA) ARCHIVED - Hyaluronates (drug specific)
Visudyne (verteporfin) (Commercial and QUEST)	No PA required				ARCHIVED - Retinal Disorders Preferred Drug Program
Visudyne (verteporfin) (Medicare Advantage)	No PA required as of 02/01/2022			Retinal Disorders Preferred Drug Program	ARCHIVED - Retinal Disorders Preferred Drug Program (MA)
Voxzogo (vosoritide)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) eff 4/1/2022	ARCHIVED - SDRP
Voyxact (sibeprenlimab-szsi)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Added effective 12/23/2025	ARCHIVED - SDRP
VPRIV (velaglucerase) (Commercial and QUEST)		10/25/2024	Fax Form		ARCHIVED - VPRIV (Comm-QUEST) ARCHIVED - VPRIV
VPRIV (velaglucerase) (Medicare Advantage)		06/26/2026	Medicare Advantage Fax Form		ARCHIVED - VPRIV (MA)
Vyalev (foscarbidopa and foslevodopa)		06/12/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Vyepti (eptinezumab-jjmr)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Vyjuvek (Beremagene geperpavec-svdt)	Effective 06/01/2024: Please contact HMSA at 808-948-6464, option #4, for drug review.
Vykoura (leucovorin calcium)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Vyloy (zolbetuximab-clzb)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Vyondys 53 (golodirsen)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Vyvgart (efgartigimod alfa-fcab)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) eff 4/1/2022	ARCHIVED - SDRP
Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc)		06/12/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) eff 7/1/2023	ARCHIVED - SDRP

W

Policy Name	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Wainua (eplontersen)	06/12/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Effective 1/1/2024	ARCHIVED - SDRP
1. Wezlana (ustekinumab-auub) (Autoimmune Preferred Drug Program) (Commercial)	01/01/2026	Refer below for Wezlana fax forms.	Commercial plan members refer to the Preferred Drug Program policy first.	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Wezlana (ustekinumag-auub) (Commercial)	01/19/2026	Commercial Fax Form	Stelara and Biosimilars (Commercial and QUEST)	ARCHIVED - Stelara and Biosimilars (Commercial)
Wezlana (ustekinumab-auub) (QUEST)	01/19/2026	QUEST Fax Form	Stelara and Biosimilars (QUEST)	ARCHIVED - Stelara and Biosimilars (QUEST)
Wezlana (ustekinumab-auub) (Medicare Advantage)	04/01/2026	Medicare Advantage Fax Form	Stelara and Biosimilars (Medicare Advantage)	ARCHIVED - Stelara (MA)
Winrevair (sotatercept-csrk)	06/12/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Effective 5/17/2024	ARCHIVED - SDRP
Wyost (denosumab-bbdz) (Commercial and QUEST)	06/27/2025	Commercial Fax Form QUEST Fax Form	Xgeva and Biosimilars (Commercial and QUEST) Added eff 6/27/2025	ARCHIVED - Xgeva (Comm-QUEST)
Wyost (denosumab-bbdz) (Medicare Advantage)	06/27/2025	Medicare Advantage Fax Form	Xgeva and Biosimilars (Medicare Advantage) Added eff 6/27/2025	ARCHIVED - Xgeva (MA)

X

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Xembify (Immune Globulin Subcutaneous [Human] – klhw, 20%) (Commercial and QUEST)		10/01/2025	Commercial Fax Form QUEST Fax Form	Subcutaneous Immunoglobulin (SCIG)	ARCHIVED - SCIG (Comm-QUEST)
Xembify (Immune Globulin Subcutaneous [Human] – klhw, 20%) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Subcutaneous Immunoglobulin (SCIG)	ARCHIVED - SCIG (MA)
Xenpozyme (olipudase alfa-rpcp)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Effective 11/1/2022	ARCHIVED - SDRP
Xeomin (incobotulinumtoxinA)		04/01/2026	Fax Form QUEST Fax Form Medicare Advantage Fax Form	Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY)	ARCHIVED - Botulinum Toxins
1. Xeomin (Botulinum Toxins Preferred Drug Program) Medicare Advantage		11/21/2025	Refer below for Xeomin Fax Forms	Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY) Preferred Drug Program	ARCHIVED - Botulinum Toxins Preferred Drug Program MA
2. Xeomin (incobotulinumtoxinA)		04/01/2026	Fax Form QUEST Fax Form Medicare Advantage Fax Form	Botulinum Toxins (BOTOX, DYSPORT, XEOMIN, MYOBLOC, and DAXXIFY)	ARCHIVED - Botulinum Toxins
Xgeva (denosumab) (Commercial and QUEST)		06/27/2025	Commercial Fax Form QUEST Fax Form	Xgeva and Biosimilars (Commercial and QUEST)	ARCHIVED - Xgeva (Comm-QUEST) ARCHIVED - Xgeva
Xgeva (denosumab) (Medicare Advantage)		06/27/2025	Medicare Advantage Fax Form	Xgeva and Biosimilars (Medicare Advantage)	ARCHIVED - Xgeva (MA)
Xolair (omalizumab) (Commercial and QUEST)		12/19/2025	Commercial Fax Form QUEST Fax Form		ARCHIVED - Xolair (Comm-QUEST) ARCHIVED - Xolair
Xolair (omalizumab) (Medicare Advantage)		01/19/2026	Medicare Advantage Fax Form	Xolair-Omlyclo	ARCHIVED - Xolair (MA)
Xybryk (denosumab-dssb) (Commercial and QUEST)		06/27/2025	Commercial Fax Form QUEST Fax Form	Xgeva and Biosimilars (Commercial and QUEST) Added eff 6/27/2025	ARCHIVED - Xgeva (Comm-QUEST)
Xybryk (denosumab-dssb) (Medicare Advantage)		06/27/2025	Medicare Advantage Fax Form	Xgeva and Biosimilars (Medicare Advantage) Added eff 6/27/2025	ARCHIVED - Xgeva (MA)
Xyntha [Factor VIII (recombinant)]	Please contact HMSA at 808-948-6464, option #4, for drug review

Y

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Yartemlea (narsoplimab-wuug)		06/12/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
Yervoy (ipilimumab)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Yescarta (axicabtagene ciloleucel)	Effective 06/24/2019: Please contact HMSA at 808-948-6464, option #4, for drug review
1. Yesintek (ustekinumab-kfce) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026		Commercial plan members refer to the Preferred Drug Program policy first.	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Yesintek (ust ekinumab-kfce (Commercial )		01/19/2026	Commercial Fax Form	Stelara and Biosimilars (Commercial-QUEST)	ARCHIVED - Stelara and Biosimilars (Commercial)
Yesintek (ustekinumab-kfce) (QUEST)		01/19/2026	QUEST Fax Form	Stelara and Biosimilars (QUEST)	ARCHIVED - Stelara and Biosimilars (QUEST)
Yesintek (ustekinumab-kfce) (Medicare Advantage)		04/01/2026	Medicare Advantage Fax Form	Stelara and Biosimilars (Medicare Advantage)	ARCHIVED - Stelara (MA)
Yimmugo (Commercial and QUEST)		07/25/2025	Commercial Fax Form QUEST Fax Form	Intravenous Immune Globulin (IVIG) - Comm-QUEST	ARCHIVED - IVIG (Comm-QUEST)
Yimmugo (Medicare Advantage)		06/26/2026		Intravenous Immune Globulin (IVIG) - MA	ARCHIVED - IVIG (MA)
Yondelis (trabectedin)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Yorvipath (palopegteriparatide)		06/12/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP
1. Yuflyma (adalimumab-aaty) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Yuflyma fax forms	Commercial plan members refer to the Preferred Drug Program policy first.	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Yuflyma (adalimumab-aaty) (Commercial)		05/25/2025	Commercial Fax Form	Humira (adalimumab) Effective 12/1/2023	ARCHIVED - Adalimumab (Humira)
Yuflyma (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QI)
1. Yusimry (adalimumab-aqvh) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Yusimry fax forms	Commercial plan members refer to the Preferred Drug Program policy first.	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Yusimry (adalimumab-aqvh) (Commercial)		05/25/2025	Commercial Fax Form	Humira (adalimumab) Effective 12/1/2023	ARCHIVED - Adalimumab (Humira)
Yusimry (Adalimumab Preferred Drug Program + Drug Specific Criteria) (QUEST)		04/01/2026		Adalimumab Preferred Drug Program (QUEST)	ARCHIVED - Adalimumab Preferred Drug Program (QI)
Yutiq (fluocinolone acetonide intravitreal implant)		06/12/2026	Commercial Fax Form QUEST Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP)	ARCHIVED - SDRP

Z

Policy Name	Notices	Current Effective Date	PA Fax Forms	Policy Notes	Archived Policies
Zaltrap (ziv-aflibercept)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Zarxio (filgrastim-sndz) (Commercial and QUEST)	No PA required	11/21/2025		Colony Stimulating Factors (CSF) – Short Acting Preferred Drug Program	ARCHIVED - CSF Short Acting Preferred Drug Program
Zarxio (filgrastim-sndz) (Medicare Advantage)	No PA required	11/21/2025		CSF – Short Acting Preferred Drug Program MA	ARCHIVED - CSF Short Acting (Preferred Drug Program) (MA)
Zepzelca (lurbinectedin)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Ziextenzo (pegfilgrastim-bmez) (CSF Long Acting Preferred Drug Program Commercial)		01/01/2026	Fax Form	Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program	ARCHIVED - CSF Long Acting Preferred Drug Program
Ziextenzo (pegfilgrastim-bmez) (CSF Long Acting Preferred Drug Program Medicare Advantage)		01/01/2026	Medicare Advantage Fax Form	Colony Stimulating Factors (CSF) – Long Acting Preferred Drug Program	ARCHIVED - CFS Long Acting Preferred Drug Program (MA)
Ziihera (zanidatamab-hrii)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
Zilbrysq (zilucoplan)		06/12/2026	Fax Form Medicare Advantage Fax Form	Specialty Drugs Requiring Precertification (SDRP) Effective 1/1/2024	ARCHIVED - SDRP
1. Zirabev (bevacizumab-bvzr) (Bevacizumab Preferred Drug Program Commercial)		01/01/2026		Bevacizumab Products - Preferred Drug Program Commercial Effective 1/1/2024	ARCHIVED - Bevacizumab Products (Commercial)
2. Zirabev (bevacizumab-bvzr) (Commercial)		06/12/2026	Commercial Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Zirabev (bevacizumab-bvzr) (Bevacizumab Preferred Drug Program Medicare Advantage)		01/01/2026		Bevacizumab Products - Preferred Drug Program MA Effective 1/1/2024	ARCHIVED - Bevacizumab Products (MA)
2. Zirabev (bevacizumab-bvzr) (Medicare Advantage)		06/12/2026	Medicare Advantage Fax Form	Global Oncology	ARCHIVED - Global Oncology
1. Zirabev (bevacizumab-bvzr) (Bevacizumab Preferred Drug Program policy QUEST)		01/01/2026		Bevacizumab Products - Preferred Drug Program QUEST Effective 1/1/2025	ARCHIVED - Bevacizumab Products (QUEST)
2. Zirabev (bevacizumab-bvzr) (QUEST)		06/12/2026	QUEST Fax Form	Global Oncology	ARCHIVED - Global Oncology
Zolgensma (onasemnogene abeparvovec-xioi)	Effective 06/24/2019: Please contact HMSA at 808-948-6464, option #4, for drug review
Zomacton™ (somatropin) (Commercial and QUEST)		01/01/2026	Fax Form	Growth Hormone	ARCHIVED - Growth Hormone
Zorbtive® (somatropin) (Commercial and QUEST)		01/01/2026	Fax Form	Growth Hormone	ARCHIVED - Growth Hormone
Zulresso (brexanolone)	Effective 06/24/2019: Please contact HMSA at 808-948-6464, option #4, for drug review
Zusduri (mitomycin)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Added effective 07/10/2025	ARCHIVED - Global Oncology
1. Zymfentra (infliximab-dyyb) (Autoimmune Preferred Drug Program) (Commercial)		01/01/2026	Refer below for Zymfentra fax forms.	Commercial plan members refer to the Preferred Drug Program policy first.	ARCHIVED - Autoimmune Preferred Drug Program (Commerical)
2. Zymfentra (infliximab-dyyb) (Commercial)		07/01/2026	Commercial Fax Form	Infliximab-Avsola-Inflectra-Remicade-Renflexis-Zymfentra	ARCHIVED - Infliximab (Comm-QUEST) ARCHIVED - Infliximab ARCHIVED - SDRP
Zymfentra (infliximab-dyyb) (QUEST)		07/01/2026	QUEST Fax Form	Infliximab-Avsola-Inflectra-Renflexis-Zymfentra (QUEST)	ARCHIVED - Infliximab (QUEST)
Zymfentra (infliximab-dyyb) (Medicare Advantage)	Drug is not covered under Medicare Part B effective 08/18/2024
Zynlonta (loncastuximab tesirine-lpyl)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Added effective 11/18/2025	ARCHIVED - Global Oncology
Zynteglo (betibeglogene autotemcel	Please contact HMSA at 808-948-6464, option #4, for drug review
Zynyz (retifanlimab-dlwr)		06/12/2026	Fax Form Medicare Advantage Fax Form	Global Oncology Effective 5/10/2023	ARCHIVED - Global Oncology

CURRENT AS OF 09/28/2026

Revision History

Date	Nature of Revision
08/03/2026	Migrated to new platform