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Medical Specialty Drug Policies: # – L

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 [PDF].

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.

View Medical Specialty Drug Policies: M – Z

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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)
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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)		 60-day provider notice 10/01/2026-11/30/2026 [PDF], in effect 12/01/2026 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)		 60-day provider notice 10/01/2026-11/30/2026 [PDF], in effect 12/01/2026 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)

   07/23/2026 Fax Form
Medicare Advantage Fax Form		 Specialty Drugs Requiring Precertification (SDRP) ARCHIVED - SDRP
Adakveo
(crizanlizumab-tmca)		   07/23/2026
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)		 60-day provider notice 10/01/2026-11/30/2026 [PDF], in effect 12/01/2026 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)		 60-day provider notice 10/01/2026-11/30/2026 [PDF], in effect 12/01/2026 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)		 60-day provider notice 10/01/2026-11/30/2026 [PDF], in effect 12/01/2026 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)		 60-day provider notice 10/01/2026-11/30/2026 [PDF], in effect 12/01/2026 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)		 60-day provider notice 10/01/2026-11/30/2026 [PDF], in effect 12/01/2026 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)		 60-day provider notice 10/01/2026-11/30/2026 [PDF], in effect 12/01/2026 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)   07/23/2026
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)		   07/23/2026

Fax Form

Specialty Drugs Requiring Precertification (SDRP)

Drug is not covered under Part B

 ARCHIVED - SDRP
Ajovy
(fremanezumab-vfrm)		   07/23/2026

 

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)

 60-day provider notice 11/01/2026-12/31/2026 [PDF], in effect 01/01/2027 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)		 60-day provider notice 10/01/2026-11/30/2026 [PDF], in effect 12/01/2026 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)		   07/23/2026 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)   07/23/2026 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)		   07/23/2026
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)		 60-day provider notice 11/01/2026-12/31/2026 [PDF], in effect 01/01/2027 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) 60-day provider notice 10/01/2026-11/30/2026 [PDF], in effect 12/01/2026 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)   07/23/2026
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  

 

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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)   10/01/2026 Medicare Advantage Fax Form
Prolia and Biosimilars (Medicare Advantage)
Added effective 06/27/2025
ARCHIVED - Prolia (MA) 
1. Bimzelx
(bimekizumab-bkzx)
(Autoimmune Preferred Drug Program) (Commercial)		 60-day provider notice 10/01/2026-11/30/2026 [PDF], in effect 12/01/2026 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)   07/23/2026
Medicare Advantage Fax Form 		Specialty Drugs Requiring Precertification (SDRP)
 ARCHIVED - SDRP
Bivigam
(human immunoglobulin) (Commercial & QUEST)		 60-day provider notice 11/01/2026-12/31/2026 [PDF], in effect 01/01/2027 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)   10/01/2026 Medicare Advantage Fax Form
Prolia and Biosimilars (Medicare Advantage)
Added effective 06/27/2025
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)		   07/23/2026

 

Commercial Fax Form
QUEST Fax Form
Medicare Advantage Fax Form

 

 Specialty Drugs Requiring Precertification (SDRP) ARCHIVED - SDRP
Briumvi
(ublituximab-xiiy)		   07/23/2026
Commercial Fax Form
QUEST Fax Form
Medicare Advantage Fax Form 		Specialty Drugs Requiring Precertification (SDRP)
Added effective 3/1/2023		 ARCHIVED - SDRP
Brixadi
(buprenorphine)		   07/23/2026 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)		   07/23/2026
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)		 60-day provider notice 10/01/2026-11/30/2026 [PDF], in effect 12/01/2026 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)		   07/23/2026

 

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)		   07/23/2026
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)   10/01/2026 Medicare Advantage Fax Form
Prolia and Biosimilars (Medicare Advantage)
Added eff 06/27/2025
ARCHIVED - Prolia (MA) 
Cosela (trilaciclib)   07/23/2026
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)		 60-day provider notice 10/01/2026-11/30/2026 [PDF], in effect 12/01/2026 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) 60-day provider notice 11/01/2026-12/31/2026 [PDF], in effect 01/01/2027 01/01/2026     ARCHIVED - Criteria Exception (Comm-QUEST)
Crysvita
(burosumab-twza)		   07/23/2026

 

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)		 60-day provider notice 10/01/2026-11/30/2026 [PDF], in effect 12/01/2026 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 Notices 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)
  07/23/2026 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)		   07/23/2026 Fax Form
Medicare Advantage Fax Form		 Specialty Drugs Requiring Precertification (SDRP)
Effective: 12/16/2024		 ARCHIVED - SDRP
Egrifta (tesamorelin acetate)   07/23/2026 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)		   07/23/2026 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)   07/23/2026 Commercial Fax Form
QUEST Fax Form

Specialty Drugs Requiring Precertification (SDRP)

Drug is not covered under Part B

 ARCHIVED - SDRP
Empaveli (pegcetacoplan)   07/23/2026
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)		 60-day provider notice 10/01/2026-11/30/2026 [PDF], in effect 12/01/2026 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)   07/23/2026
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)   10/01/2026 Medicare Advantage Fax Form
Prolia and Biosimilars (Medicare Advantage)
Added effective 06/27/2025
ARCHIVED - Prolia (MA) 
Enspryng
(satralizumab-mwge)		   07/23/2026
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)		 60-day provider notice 10/01/2026-11/30/2026 [PDF], in effect 12/01/2026 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)		   07/23/2026
Commercial Fax Form
QUEST Fax Form
Medicare Advantage Fax Form 		Specialty Drugs Requiring Precertification (SDRP) ARCHIVED - SDRP
Exdensur (depemokimab-ulaa)   07/23/2026 Commercial Fax Form
QUEST Fax Form
Medicare Advantage Fax Form		 Specialty Drugs Requiring Precertification (SDRP) ARCHIVED - SDRP
Exondys 51 (eteplirsen)   07/23/2026 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)   07/23/2026
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)		 60-day provider notice 11/01/2026-12/31/2026 [PDF], in effect 01/01/2027 01/01/2026 Fax Form Leuprolide-Lupron ARCHIVED - Leuprolide (Comm-QI)
Fesilty (fibrinogen, human–chmt)   07/23/2026
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)		 60-day provider notice 11/01/2026-12/31/2026 [PDF], in effect 01/01/2027 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)   07/23/2026
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)		   07/23/2026 Commercial Fax Form
QUEST Fax Form
Medicare Advantage Fax Form		 Specialty Drugs Requiring Precertification (SDRP) ARCHIVED - SDRP
Gammagard Liquid (human immunoglobulin)
(Commercial & QUEST)		 60-day provider notice 11/01/2026-12/31/2026 [PDF], in effect 01/01/2027 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) 60-day provider notice 11/01/2026-12/31/2026 [PDF], in effect 01/01/2027 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)		 60-day provider notice 11/01/2026-12/31/2026 [PDF], in effect 01/01/2027 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)		 60-day provider notice 11/01/2026-12/31/2026 [PDF], in effect 01/01/2027 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)		 60-day provider notice 11/01/2026-12/31/2026 [PDF], in effect 01/01/2027 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)		 60-day provider notice 11/01/2026-12/31/2026 [PDF], in effect 01/01/2027 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)   07/23/2026 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) 60-day provider notice 10/01/2026-11/30/2026 [PDF], in effect 12/01/2026 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])		   07/23/2026 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)   07/23/2026 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)		 60-day provider notice 10/01/2026-11/30/2026 [PDF], in effect 12/01/2026 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)		 60-day provider notice 10/01/2026-11/30/2026 [PDF], in effect 12/01/2026 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) 60-day provider notice 10/01/2026-11/30/2026 [PDF], in effect 12/01/2026 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)
Icotyde (icotrokinra)
(Autoimmune Preferred Drug Program) (Commercial)		 60-day provider notice 10/01/2026-11/30/2026 [PDF], in effect 12/01/2026     Added to the Autoimmune Preferred Drug Program (Commercial) policy eff. 12/01/2026.  

1. Idacio (adalimumab-aacf)

(Autoimmune Preferred Drug Program)  (Commercial)

 60-day provider notice 10/01/2026-11/30/2026 [PDF], in effect 12/01/2026 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)		 60-day provider notice 10/01/2026-11/30/2026 [PDF], in effect 12/01/2026 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)   07/23/2026 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)		 60-day provider notice 10/01/2026-11/30/2026 [PDF], in effect 12/01/2026 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)		 60-day provider notice 10/01/2026-11/30/2026 [PDF], in effect 12/01/2026 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) 60-day provider notice 11/01/2026-12/31/2026 [PDF], in effect 01/01/2027 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)		   07/23/2026 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)   10/01/2026 Medicare Advantage Fax Form Prolia and Biosimilars (Medicare Advantage)
Added eff 06/27/2025		 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)		   07/23/2026 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)   07/23/2026 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)		 60-day provider notice 10/01/2026-11/30/2026 [PDF], in effect 12/01/2026 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)		 60-day provider notice 10/01/2026-11/30/2026 [PDF], in effect 12/01/2026 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)		   07/23/2026 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)		   07/23/2026 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) 60-day provider notice 11/01/2026-12/31/2026 [PDF], in effect 01/01/2027 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
Lumvoa
(veligrotug-vvze)		   07/23/2026 Commercial Fax FormMedicare Advantage Fax FormQUEST Fax Form

Specialty Drugs Requiring Precertification (SDRP)

Added eff 07/23/2026

 ARCHIVED - SDRP
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

60-day provider notice 11/01/2026-12/31/2026 [PDF], in effect 01/01/2027

 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)		 60-day provider notice 11/01/2026-12/31/2026 [PDF], in effect 01/01/2027 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
CURRENT AS OF 11/05/2026

Revision History

Date Nature of Revision
11/05/2026

60-day notice has been posted for Intravenous Immune Globulin (IVIG) (Commercial and QUEST)
11/01/2026

60-day notices have been posted for the drugs covered under the following policies:

  • Criteria Exception (Commercial and QUEST)
  • Intravenous Immune Globulin (IVIG) (Commercial and QUEST)
  • Leuprolide (Commercial and QUEST)
  • Supprelin LA (Commercial and QUEST)

The following drugs will be added to the Intravenous Immune Globulin (IVIG) (Commercial and QUEST) policy, eff. 01/01/2027:

  • Qivigy (Commercial and QUEST)
10/30/2026

Splitting article to increase user experience.
10/02/2026

Specialty Drugs Requiring Precertification policy eff 07/23/2026 has been posted for the drugs covered under this policy.

The following drugs have been added to the Specialty Drugs Requiring Precertification policy, eff. 07/23/2026:

  • Lumvoa (veligrotug-vvze)
  • Trutakna (atacicept-vymj)
10/01/2026

Added fax form links for Nemluvio (Commercial) and Nemluvio (QUEST).
09/30/2026

60-day notices have been posted for Autoimmune (AI) Preferred Drug Program (Commercial) policy for the drugs covered under this policy.

The following drugs will be added to the Autoimmune (AI) Preferred Drug Program (Commercial) policy, eff. 12/01/2026:

  • Icotyde (icotrokinra) (Autoimmune Preferred Drug Program policy)
  • 1. ustekinumab-aauz (unbranded Otulfi) (Autoimmune Preferred Drug Program)
  • 1. ustekinumab-stba (unbranded Steqeyma) (Autoimmune Preferred Drug Program)
09/30/2026

Prolia and Biosimilars (Medicare Advantage) policy eff 10/01/2026 has been posted for the drugs covered under this policy. 60-day notices have been removed.
09/28/2026

Migrated to new platform