Medical Policy Updates
View any medical policy or medical necessity criteria changes that will be implemented in the next 60 days or more.
- BCBSWY requires prior authorization for certain health care services, treatments, prescription drugs, and durable medical equipment (DME) before a member can receive them, except in emergency.
- Prior authorization is based on BCBSWY medical policy. Medical policy and criteria changes that will be implemented in the next 60 days are listed below.
- This information is not intended to instruct providers or members on benefit changes or authorization requirements. Members can login to YourWyoBlue.com to search prior authorization requirements for their benefit plan. Providers can learn more about prior authorization requirements here →
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Medical Policy Updates
Use the Policy Number, Policy Title, or CPT Codes to find and view the full medical policy.
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| Policy # | Policy Title | Change Type | Summary of Changes | Effective Date | Provider Notification Date |
|---|---|---|---|---|---|
| myprime.com | Zeposia | UPDATE | *Removal requirement “the prescriber has performed an ECG within 6 months prior to initiating treatment” since it no longer aligns with FDA labeling | 7/1/26 | 3/9/26 |
| myprime.com | Weight Management PAQL | UPDATE | *For diagnosis of MASH: updated the requirement restricting to “Wegovy” to “Wegovy injection” since only the injectable formulations are approved for the treatment of MASH *Pediatric weight loss requirements updated any mention of “Wegovy” to “Wegovy injection” since only the injectable formulations are approved for to treat pediatric patients *Quantity limit requirements were updated to limit the tablets to one per day to align with FDA labeling *Quantity limit requirements evaluating titration doses for maintenance therapy were updated to include the new tablet formulations |
6/1/26 | 3/9/26 |
| myprime.com | PCSK9 Inhibitors PAQL | UPDATE | *Removed the diagnosis of hyperlipidemia and the three 10-year ASCVD risk groups and added the diagnoses of hypercholesterolemia and reduce the risk of major adverse cardiovascular events to follow recent FDA labeling updates for each target
*Updated renewal criteria to include the new diagnoses of hypercholesterolemia and reduce the risk of major adverse CV events to match the initial criteria |
5/15/26 | 3/9/26 |
| 02.04.002 | Germline Genetic Testing for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers (BRCA1, BRCA2, PALB2) | DELETE | Archiving the criteria. | 5/4/26 | 3/2/26 |
| 12.01.010 | Erythropoietins - Aranesp, Epogen, Procrit, Mircera, Retacrit | UPDATE | Updated policy information, including updated policy posiion information. | 5/1/26 | 3/2/26 |
| 05.01.052 | Gene Therapies for Aromatic L-amino Acid Decarboxylase Deficiency | NEW | Implementation of NEW guidelines. | 5/1/26 | 3/2/26 |
| 05.21.236 | Aucatzyl | NEW | Implementation of NEW guidelines. | 5/1/26 | 3/2/26 |
| 05.01.046 | Gene Therapies for Duchenne Muscular Dystrophy (Elevidys) | NEW | Implementation of NEW guidelines. | 5/1/26 | 3/2/26 |
| 12.01.069 | Leqvio (Inclisiran) | UPDATE | Updated policy information, including updated policy posiion information. | 5/1/26 | 3/2/26 |
| 05.01.030 | Treatment of Hereditary Transthyretin-Mediated Amyloidosis in Adult Patients – Onpattro, Amvuttra | UPDATE | Updated policy information, including updated policy posiion information. | 5/1/26 | 3/2/26 |
| 05.01.048 | Gene Therapies for Sickle Cell Disease - Casgevy, Lyfgenia | UPDATE | Updated policy information, including updated policy posiion information. | 5/1/26 | 3/2/26 |
| 05.01.040 | Givosiran for Acute Hepatic Porphyria - Givlaari | UPDATE | Updated policy information, including updated policy posiion information. | 5/1/26 | 3/2/26 |
| 02.04.059 | Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies | UPDATE | Clinical evidence to support the policy position was updated and CPT 90641 was added. There is no change to the policy position statement listed. | 4/27/26 | 2/23/26 |
| 02.04.063 | Use of Common Genetic Variants (Single Nucleotide Variants) to Predict Risk of Nonfamilial Breast Cancer | UPDATE | Clinical evidence to support the policy position was updated and CPT 90641 was added. There is no change to the policy position statement listed. | 4/27/26 | 2/23/26 |
| 02.04.093 | Genetic Cancer Susceptibility Panels Using Next Generation Sequencing | UPDATE | Clinical evidence to support the policy position was updated and CPT 90641 was added. Policy statements were revised to reflect ASCO and NCCN recommendations of multigene panels. Major and minor revisions were made to the policy guidelines section to reflect these recommendations. | 4/27/26 | 2/23/26 |
| 02.04.097 | Microarray-Based Gene Expression Profile Testing for Multiple Myeloma Risk Stratification | UPDATE | Clinical evidence to support the policy position was updated & references added. Removed mention of MyPRS test availability. Policy statement unchanged. | 4/27/26 | 2/23/26 |
| 05.01.005 | Off Label Use of Botulinum Toxin | UPDATE | Clinical evidence to support the policy position was reviewed. There is no change to the policy position statement listed. | 4/27/26 | 2/23/26 |
| 05.01.006 | Off Label Use of Human Growth Hormone | UPDATE | Clinical evidence to support the policy position was reviewed. There is no change to the policy position statement listed. | 4/27/26 | 2/23/26 |
| 05.01.008 | Intravenous Antibiotic Therapy and Associated Diagnostic Testing for Lyme Disease | UPDATE | Clinical evidence to support the policy position was reviewed. There is no change to the policy position statement listed. | 4/27/26 | 2/23/26 |
| 05.01.017 | Repository Corticotropin Injection | UPDATE | Clinical evidence to support the policy position was reviewed. There is no change to the policy position statement listed. | 4/27/26 | 2/23/26 |
| 05.01.043 | Therapeutic Radiopharmaceuticals for Prostate Cancer | UPDATE | Clinical evidence to support the policy position was reviewed. There is no change to the policy position statement listed. | 4/27/26 | 2/23/26 |
| 06.01.006 | Miscellaneous (Noncardiac, Nononcologic) Applications of Fluorine 18 Fluorodeoxyglucose Positron Emission Tomography | UPDATE | Clinical evidence to support the policy position was reviewed. There is no change to the policy position statement listed. | 4/27/26 | 2/23/26 |
| 06.01.020 | Cardiac Applications of Positron Emission Tomography Scanning | UPDATE | Clinical evidence to support the policy position was reviewed. There is no change to the policy position statement listed. | 4/27/26 | 2/23/26 |
| 06.01.024 | Magnetic Resonance Spectroscopy | UPDATE | Clinical evidence to support the policy position was reviewed. There is no change to the policy position statement listed. | 4/27/26 | 2/23/26 |
| 06.01.054 | Dopamine Transporter Single-Photon Emission Computed Tomography | UPDATE | Clinical evidence to support the policy position was reviewed. Minor editorial changes to policy guidelines; policy statements unchanged. | 4/27/26 | 2/23/26 |
| 07.01.019 | Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence | UPDATE | Clinical evidence to support the policy position was reviewed. There is no change to the policy position statement listed. | 4/27/26 | 2/23/26 |
| 08.03.010 | Cognitive Rehabilitation | UPDATE | Clinical evidence to support the policy position was reviewed. Policy focus and scope were significantly revised. The first statement now addresses CR for moderate to severe TBI. The second statement adds mild TBI, mild cognitive impairment and Alzheimer's disease, while removing broad dementia and seizure disorders, autism spectrum disorder, and postencephalopathy. | 4/27/26 | 2/23/26 |
| 12.01.039 | Rituxan Oncology - Rituxan Hycela | UPDATE | Title changed to Rituxan (Rituximab). | 4/27/26 | 2/23/26 |
| 12.01.025 | Nplate | DELETE | Archiving the criteria. | 4/20/26 | 2/17/26 |
| 12.01.033 | Eribitux | DELETE | Archiving the criteria. | 4/20/26 | 2/17/26 |
| 12.01.044 | Implantable Probuphine | DELETE | Archiving the criteria. | 4/20/26 | 2/17/26 |
| 12.01.050 | Synagis | DELETE | Archiving the criteria. | 4/20/26 | 2/17/26 |
| 12.01.053 | Vivitrol | DELETE | Archiving the criteria. | 4/20/26 | 2/17/26 |
| 05.01.013 | Pharmacologic Treatments for Metabolic Dysfunction-Associated Steatohepatitis | NEW | Implementation of NEW guidelines. | 4/20/26 | 2/17/26 |
| 12.01.054 | Xiaflex | UPDATE | Updated policy information, including updated policy position information. | 4/20/26 | 2/17/26 |
| 02.01.050 | Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders | DELETE | Archiving the criteria. | 4/20/26 | 2/17/26 |
| 02.01.061 | Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders | UPDATE | Clinical evidence to support the policy position was updated, guidelines & references added. Information added to Policy Guidelines regarding biomarker legislation and regarding updated global guideline. There is no change to the policy position statement listed. | 4/20/26 | 2/17/26 |
| 02.01.093 | Antigen Leukocyte Antibody Test | UPDATE | Clinical evidence to support the policy position was updated & references added. There is no change to the policy position statement listed. | 4/20/26 | 2/17/26 |
| 02.02.008 | Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry | UPDATE | Clinical evidence to support the policy position was updated & references added. There is no change to the policy position statement listed. | 4/20/26 | 2/17/26 |
| 02.04.115 | Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies | UPDATE | Clinical evidence to support the policy position was updated, guidelines & references added. Policy statement changed. Made revisions to policy guidelines and included a table of gene variants of interest. Table 2 within the background section was updated to include 2 additional tests from Guardant Health. The coding table was updated to reflect these additions. | 4/20/26 | 2/17/26 |
| 02.04.013 | Genetic Testing for Alzheimer Disease | UPDATE | Added 96041 and updated dementia code range from F03.90-F03.91 and added new code range for unspecificed dementia of F03.90-F03.C4. There is no change to the policy position statement listed. | 4/20/26 | 2/17/26 |
| 02.04.139 | Genetic Testing for Heterozygous Familial Hypercholesterolemia | UPDATE | Clinical evidence to support the policy position was updated & references added. There is no change to the policy position statement listed. | 4/20/26 | 2/17/26 |
| 02.04.159 | Laboratory Testing Investigational Services | UPDATE | Clinical evidence to support the policy position was updated and CPT 90641 was added. There is no change to the policy position statement listed. | 4/20/26 | 2/17/26 |
| 02.04.041 | Noninvasive Techniques for the Evaluation and Monitoring of Patients With Chronic Liver Disease | UPDATE | Clinical evidence to support the policy position was updated & references added. Substantive policy statement edits; intent unchanged. | 4/20/26 | 2/17/26 |
| 15.01.002 | Applied Behavior Analysis for Autism Spectrum Disorder in Adults | UPDATE | Clinical evidence to support the policy position reviewed and there is no change to the policy position statement listed. | 4/20/26 | 2/10/26 |
| myprime.com | Weight Management PAQL | UPDATE | *Removal of the FIB-4 score as part of the diagnosis confirmation for the diagnosis of MASH. | 4/1/26 | 2/3/26 |
| myprime.com | Resmetirom PAQL | UPDATE | *Removal of the FIB-4 score as part of the diagnosis confirmation for the diagnosis of MASH to align with the Weight Management PAQL. | 4/1/26 | 2/3/26 |
| myprime.com | SGLT STQL | UPDATE | *Updated CKD, heart failure, and cardiac risk requirements for Jardiance, Inpefa, and Farxiga to include the separate FDA labeled diagnoses for each individual agent to ensure continued rebate eligibility. | 4/1/26 | 2/3/26 |
| 02.01.038 | Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease | UPDATE | Clinical evidence to support the policy position was updated & references added. There is no change to the policy position statement listed. | 3/23/26 | 1/26/26 |
| 02.01.089 | Laser Treatment of Onychomycosis | UPDATE | Clinical evidence to support the policy position was updated & references added. There is no change to the policy position statement listed. | 3/23/26 | 1/26/26 |
| 02.04.007 | Urinary Biomarkers for Cancer Screening, Diagnosis, and Surveillance | UPDATE | Clinical evidence to support the policy position was updated & references added. There is no change to the policy position statement listed. | 3/23/26 | 1/26/26 |
| 02.04.127 | Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis | UPDATE | Clinical evidence to support the policy position was updated & references added. There is no change to the policy position statement listed. | 3/23/26 | 1/26/26 |
| 02.04.128 | Genetic Testing for Fanconi Anemia | UPDATE | Clinical evidence to support the policy position was updated & references added. There is no change to the policy position statement listed. | 3/23/26 | 1/26/26 |
| 02.04.135 | Testing Serum Vitamin D Levels | UPDATE | Clinical evidence to support the policy position was updated & references added. There is no change to the policy position statement listed. | 3/23/26 | 1/26/26 |
| 02.04.147 | Next-Generation Sequencing for the Assessment of Measurable Residual Disease | UPDATE | Clinical evidence to support the policy position was updated & references added. There is no change to the policy position statement listed. | 3/23/26 | 1/26/26 |
| 02.04.015 | Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Diseases Associated With High Bone Turnover | UPDATE | Clinical evidence to support the policy position was updated & references added. There is no change to the policy position statement listed. | 3/23/26 | 1/26/26 |
| 02.04.150 | Serologic Genetic and Molecular Screening for Colorectal Cancer | UPDATE | Clinical evidence to support the policy position was updated & references added. ICOs separated and added separate PICO for Shield test. Position statement added: "Epigenomic and genomic cell-free DNA (cfDNA) blood-based testing with Guardant Shield is considered investigational for all indications (see Policy Guidelines). | 3/23/26 | 1/26/26 |
| 02.04.151 | Genetic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Advanced Cancer | UPDATE | Clinical evidence to support the policy position was updated & references added. Title changed to include all genetic biomarkers for targeted therapy as all reference medical policies regarding targeted therapy were collapsed into this single policy (2.04.155, 2.04.156, 2.04.157, 2.04.45, 2.04.53, and 2.04.77,). Medically necessary policy statements from these policies were incorporated. | 3/23/26 | 1/26/26 |
| 02.04.023 | Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease and Venous Thromboembolic Disorders | UPDATE | Clinical evidence to support the policy position was updated & references added. There is no change to the policy position statement listed. | 3/23/26 | 1/26/26 |
| 02.04.056 | Immune Cell Function Assay | UPDATE | Clinical evidence to support the policy position was updated & references added. There is no change to the policy position statement listed. | 3/23/26 | 1/26/26 |
| 02.04.058 | Nerve Fiber Density Measurement | UPDATE | Clinical evidence to support the policy position was updated & references added. There is no change to the policy position statement listed. | 3/23/26 | 1/26/26 |
| 02.04.062 | Multimarker Serum Testing Related to Ovarian Cancer | UPDATE | Clinical evidence to support the policy position was updated & references added. There is no change to the policy position statement listed. | 3/23/26 | 1/26/26 |
| 02.04.065 | Biomarker Testing in Risk Assessment and Management of Cardiovascular Disease | UPDATE | Clinical evidence to support the policy position was updated & references added. There is no change to the policy position statement listed. | 3/23/26 | 1/26/26 |
| 02.04.066 | Serum Biomarker Human Epididymis Protein 4 | UPDATE | Clinical evidence to support the policy position was updated & references added. There is no change to the policy position statement listed. | 3/23/26 | 1/26/26 |
| 06.01.033 | Wireless Capsule Endoscopy for Gastrointestinal Disorders | UPDATE | Clinical evidence to support the policy position was updated & references added. There is no change to the policy position statement listed. | 3/23/26 | 1/26/26 |
| 06.01.049 | Computed Tomography Perfusion Imaging of the Brain | UPDATE | Clinical evidence to support the policy position was updated & references added. There is no change to the policy position statement listed. | 3/23/26 | 1/26/26 |
| 07.01.165 | Radiofrequency Coblation Tenotomy for Musculoskeletal Conditions | UPDATE | Clinical evidence to support the policy position was updated & references added. There is no change to the policy position statement listed. | 3/23/26 | 1/26/26 |
| 07.01.101 | Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome | UPDATE | Clinical evidence to support the policy position was updated & references added. An evidence review for the newly FDA-approved Genio HNS system was added. Medically necessary statement for HNS now specifically cites the Inspire device. A new policy statement is added that HNS using other FDA-approved devices (e.g., Genio) is considered investigational for treating clinically significant OSA syndrome. | 3/23/26 | 1/26/26 |
| 08.01.016 | Chemical Peels | UPDATE | Clinical evidence to support the policy position was updated & references added. There is no change to the policy position statement listed. | 3/23/26 | 1/26/26 |
| 02.04.155 | Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Prostate Cancer (BRCA1/2, Homologous Recombination Repair Gene Alterations, NTRK Gene Fusion | DELETE | Archiving the criteria. | 3/23/26 | 1/26/26 |
| 02.04.156 | Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Ovarian Cancer (BRCA1, BRCA2, Homologous Recombination Deficiency, NTRK) | DELETE | Archiving the criteria. | 3/23/26 | 1/26/26 |
| 02.04.157 | Somatic Biomarker Testing for Immune Checkpoint Inhibitor Therapy (BRAF, MSI/MMR, PD-L1, TMB) | DELETE | Archiving the criteria. | 3/23/26 | 1/26/26 |
| 02.04.045 | Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Non-Small-Cell Lung Cancer (EGFR, ALK, BRAF, ROS1, RET, MET, KRAS, HER2, PD-L1, TMB) | DELETE | Archiving the criteria. | 3/23/26 | 1/26/26 |
| 02.04.053 | Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Metastatic Colorectal Cancer (KRAS, NRAS, BRAF, and HER2) | DELETE | Archiving the criteria. | 3/23/26 | 1/26/26 |
| 02.04.077 | Somatic Genetic Testing to Select Individuals with Melanoma or Glioma for Targeted Therapy (BRAF) | DELETE | Archiving the criteria. | 3/23/26 | 1/26/26 |
| 02.01.049 | Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) for Benign Prostatic Hypertrophy | NEW | Implementation of NEW guidelines. | 3/9/26 | 1/12/26 |
| myprime.com | ADHD | UPDATE | *Increased quantity limits for 32 GPIs within the FDA labeled maximums. *Removed obsolete target Evekeo ODT |
4/1/26 | 1/6/26 |
| myprime.com | Afrezza | UPDATE | *Removed non-preferred section (includes these products - Admelog, Apidra, Insulin aspart, Insulin lispro, and Kirsty) from the Target Agent/Preferred Agent table at the top of the PA criteria. | 4/1/26 | 1/6/26 |
| myprime.com | Amifampridine | UPDATE | *Changed length of approval to 12 months due to the new default approval lengths per regulations *Standardized Continuation of Therapy to allow members already on therapy to bypass additional PA requirements (e.g., age, diagnostics) |
4/1/26 | 1/6/26 |
| myprime.com | Antidepressant | UPDATE | *Removed obsolete (6/6/2025) Viibryd titration pack (GPI: 58120088106410) from QL target *Correction to add branded generic Bupropion ER to step tablet |
4/1/26 | 1/6/26 |
| myprime.com | Atypical Antipsychotics | UPDATE | *Removed obsolete (8/31/2025) Vraylar titration pack (GPI: 5940001810B220) from QL target | 4/1/26 | 1/6/26 |
| myprime.com | Arikayce | UPDATE | *Edited diagnostic criteria to match requirements of IDSA guidelines (that ALL clinical findings [not just one clinical finding] are required) | 4/1/26 | 1/6/26 |
| myprime.com | Biologic Immunomodulators OP2 | UPDATE | 10.15.25 Ad Hoc *Added Simponi weight requirement for pediatric patients for a diagnosis of ulcerative colitis. FDA labeling requires pediatric patients to weigh 15 kg or greater. *Step Table: Moved Rinvoq to Step 2 for Crohn's disease (CD) and ulcerative colitis (UC) due to update in FDA labeling for these two indications. |
4/1/26 | 1/6/26 |
| myprime.com | Biologic Immunomodulators OP2 | UPDATE | Mid-Year *QL Target Agent: Updated Cimzia. Also updated member friendly language to reference "Syringes" instead of "Kits" for clarity due to there being 1- and 2-syringe maintenance kits available. *Updated previous immunomodulator use requirements to exclude sample use and include systemic targeted synthetic small molecule drugs as an option *Added age callout (6 years or older) to Tremfya weight requirement for pediatric patients for PS or PsA to match FDA labeling. This ensures the weight requirement of 40 kg would not apply to pediatric patients less than 6 years old if the age population gets expanded. *QL: Added psoriatic arthritis (PsA) diagnosis to Xeljanz oral solution requirements due to update to FDA labeling *Added Otezla XR, Rhapsido, and Tyruko to "Agents NOT to be used Concomitantly" table December Ad Hoc *Bimzelx moving to a step 3a for all FDA labeled indications to align with rebate requirments. |
4/1/26 | 1/6/26 |
| myprime.com | Brensocatib | NEW | New implementation | 4/1/26 | 1/6/26 |
| myprime.com | CFTR | UPDATE | *Changed length of approval to 12 months *Standardized renewal clinical benefit check |
4/1/26 | 1/6/26 |
| myprime.com | Cibinqo | UPDATE | *Updated previous immunomodulator use requirement to exclude sample use, state "a" instead of "another", and include systemic targeted synthetic small molecule drugs as an option *Changed length of approval to the new default approval length per regulations (12 months) *Added Otezla XR, Rhapsido, and Tyruko to "Agents NOT to be used Concomitantly" table |
4/1/26 | 1/6/26 |
| myprime.com | Daybue | UPDATE | *Changed length of approval to 12 months *Removed criterion in Initial Evaluation for baseline status of RTT symptoms. This criterion had been in place to support a detailed Renewal Evaluation benefit check, but renewal benefit check is now general |
4/1/26 | 1/6/26 |
| myprime.com | DPP-4 Inhibitors and Combinations | UPDATE | *Removed the obsolete brand name products Oseni and Kasano. The "Generic Brand name" products (G-N) are still available Alogliptin/pioglitazone and Alogliptin/metformin | 4/1/26 | 1/6/26 |
| myprime.com | Efgartigimod | UPDATE | *QL increased from 4 syringes per 50 days to 4 syringes per 28 days to align with new myasthenia gravis labeling recommendations *Updated combination use question in renewal criteria to only apply to a diagnosis of gMG to align with initial criteria |
4/1/26 | 1/6/26 |
| myprime.com | Elmiron | UPDATE | *Addition of Smart Edit *Updated approval length for PA to 12 months per state regulation - PS to CSReg |
4/1/26 | 1/6/26 |
| myprime.com | Erythropoietin | UPDATE | *Changed approval length to 12 months per state regulations - PS to CSReg *Correction: Aranesp Renewal - Added "/or" after "and" within Hgb/Hct lab criteria requirement. This allows either Hgb OR Hct levels to be accepted. *Correction: Specifically noted that "hematocrit and/or hemoglobin" lab values need to be obtained within 30 days in the Mircera renewal criteria |
4/1/26 | 1/6/26 |
| myprime.com | Esketamine | UPDATE | *Adjusted order in renewal to make it clearer that criteria goes through clinical benefit check regardless of indication and then MDD has separate requirement for oral antidepressant use in combination with requested agent. Indication is required because MDD with acute suicidal ideation or behavior requires patient to use oral antidepressants in combination with esketamine. | 4/1/26 | 1/6/26 |
| myprime.com | Factor VIII and von Willebrand Factor | UPDATE | *Updated Jivi indication to include patients greater than or equal to 7 years old *Removed Stimate nasal spray as an example of a desmopressin product for von Willebrand Disease due to no longer being on the market *Updated approval length for PA to 12 months per state regulation - PS to CSReg |
4/1/26 | 1/6/26 |
| myprime.com | GLP-1 Agonists | UPDATE | *Removed the step through metformin/insulin requirement due to contracting *Removed other diagnoses (CKD, MASH/NASH, cardiovascular disease) that were allowed as a bypass to the metformin/insulin step *Replaced Oseni and Kazano with in the disallowance therapy requirement for DPP4s with Alogliptin/metformin, Alogliptin/pioglitazone as the brand names (Oseni and Kazano) will be going obsolete but the branded generic products are available *Added Trijardy to the disallowance therapy requirement as it contains a DPP-4 |
4/1/26 | 1/6/26 |
| myprime.com | Growth Hormone | UPDATE | 10.15 Ad Hoc *Corrected "BOTH" to "ONE" in Children: short acting growth hormone module at initial review for SBS age check *Reverted preferred agent criteria for short and long-acting agents in Adult module and Children Long-acting Growth Hormone module in regard to previous use of preferred agents. This criteria point was changed to "ONE" preferred agent during previous annual review as part of standardization update, but intent is to allow patient to be approved with use of ANY preferred agents for at least 12 months (allowing use of multiple preferred agents with a cumulative use of at least 12 months). *Removed the word "therapy" from Adult module renewal criteria in criteria checking patient is monitored for adverse effects of GH. *Updated location of examples listed for clinical benefit for diagnosis of AIDS wasting/cachexia. |
4/1/26 | 1/6/26 |
| myprime.com | Harliku | NEW | New implementation | 4/1/26 | 1/6/26 |
| myprime.com | Hepatitis C Direct Acting Antivirals | UPDATE | 10.15 Ad Hoc *Added specialist requirement to each module to provide a bypass for patients who are more complicated and may need to see a specialist beyond their primary MD |
4/1/26 | 1/6/26 |
| myprime.com | Hereditary Angioedema | UPDATE | *Added requirement for Dawnzera to trial extended dosing *Added step requirement for Ekterly and Ruconest through generic icatibant per trade recommendation *Changed length of approval to 12 months *Standardized Continuation of Therapy to allow members already on therapy to bypass additional PA requirements (e.g., age, diagnostics) |
4/1/26 | 1/6/26 |
| myprime.com | Hyperhidrosis | UPDATE | *Changed length of approval to the new default approval lengths per regulations *Added "ONE" before prerequisite 20% aluminum based topical antiperspirant *Updated approval length for PA to 12 months per state regulation - PS to CSReg |
4/1/26 | 1/6/26 |
| myprime.com | Hypoactive Sexual Desire Disorder (HSDD) | UPDATE | *Addition of FSIAD in criteria point evaluating indication is not due to any of the following reasons since we allow FSIAD within criteria *Addition of target agent names (Addyi, Vyleesi) in criteria restricting combination use with another target agent for initial and renewal - no change to clinical intent *Updated approval length for PA to 12 months per state regulation - PS to CSReg |
4/1/26 | 1/6/26 |
| myprime.com | IL-4 Inhibitor | UPDATE | *Updated previous immunomodulator use requirement to exclude sample use and include systemic targeted synthetic small molecule drugs as an option *Asthma: Added example of 'asthma control therapy' to uncontrolled asthma requirement wording for clarity *Asthma: Added additional requirement/pathway for asthma to allow a bypass of uncontrolled asthma requirements (within the past 12 months) if the patient was treated with a biologic immunomodulator for asthma within the past 12 months since biologic agents (e.g., Dupixent, Xolair) have been shown to decrease exacerbations. Treatment on samples is not approvable. *BP: Updated wording of requirement confirming the diagnosis to state "after evaluating findings from" to clarify that not all assessments need to be consistent with a diagnosis of BP *COPD: Updated wording of not allowing use of samples for previous biologic use to "excluding sample use" for clarity *CRSwNP: Updated confirmation test to state "nasal" endoscopy and moved each test to its own line for clarity *CSU: Updated requirement assessing if the patient is currently treated with medication known to cause or worsen urticaria to be a singular requirement and to be attestation. *CSU: Moved 2-week duration requirement to the trial of a second-generation H1-antihistamine titrated up to 4 times above the FDA maximum dose based on guideline treatment algorithm *CSU: Updated wording of second-generation H1-antihistamine trial requirements for clarity and to capture desired intent *CSU: Added required concomitant therapy with a second-generation H1-antihistamine based on guidelines, clinical trials, and competitive analysis *Asthma: Updated concurrent inhaled corticosteroid (ICS) requirements to include the scenario that a patient is currently treated with a biologic immunomodulator other than the requested agent. The additional allowable pathway for patients currently treated with the requested agent would also be appropriate for patients currently treated with a different biologic immunomodulator for asthma. At this requirement, whether a patient is currently treated with a biologic/requested agent will be attestation. *Changed length of approval to the new default approval length per regulations (12 months) *(Renewal): Removed specific improvement/stability (clinical benefit) requirements for asthma and standardized the clinical benefit requirement; no specific examples/instructions are listed in FDA labeling. *Added Otezla XR, Rhapsido, and Tyruko to "Agents NOT to be used Concomitantly" table |
4/1/26 | 1/6/26 |
| myprime.com | IL-5 Inhibitor | UPDATE | *Asthma: Added example of 'asthma control therapy' to uncontrolled asthma requirement wording for clarity *Asthma: Added additional requirement/pathway for asthma to allow a bypass of uncontrolled asthma requirements (within the past 12 months) if the patient was treated with a biologic immunomodulator for asthma within the past 12 months since biologic agents (e.g., Dupixent, Xolair) have been shown to decrease exacerbations. Treatment on samples is not approvable. *COPD: Updated wording of not allowing use of samples for previous biologic use to "excluding sample use" for clarity (no change to intent) *EGPA: Added "used in the treatment of EGPA" to OCS intolerance/hypersensitivity requirement to confirm the intolerance is for an OCS dosed for the treatment of EGPA *CRSwNP: Updated confirmation test to state "nasal" endoscopy and moved each test to its own line for clarity *Asthma: Updated concurrent inhaled corticosteroid (ICS) requirements to include the scenario that a patient is currently treated with a biologic immunomodulator other than the requested agent. The additional allowable pathway for patients currently treated with the requested agent would also be appropriate for patients currently treated with a different biologic immunomodulator for asthma. At this requirement, whether a patient is currently treated with a biologic/requested agent will be attestation. *Updated specialist requirement by adding specific examples for each indication *Changed length of approval to the new default approval length per regulations (12 months) - move from CSReg to PS *(Renewal): Removed specific improvement/stability (clinical benefit) requirements for asthma, EGPA, and HES and standardized the clinical benefit requirement; no specific examples/instructions are listed in FDA labeling. *Added Otezla XR, Rhapsido, and Tyruko to "Agents NOT to be used Concomitantly" table |
4/1/26 | 1/6/26 |
| myprime.com | IL-13 Antagonist | UPDATE | *Updated previous immunomodulator use requirement to exclude sample use, state "a" instead of "another", and include systemic targeted synthetic small molecule drugs as an option *Changed length of approval to the new default approval length per regulations (12 months) *Added Otezla XR, Rhapsido, and Tyruko to "Agents NOT to be used Concomitantly" table |
4/1/26 | 1/6/26 |
| myprime.com | IL-31 Inhibitor | UPDATE | *Updated previous immunomodulator use requirement to exclude sample use, state "a" instead of "another", and include systemic targeted synthetic small molecule drugs as an option *Changed length of approval to the new default approval length per regulations (12 months) *Added Otezla XR, Rhapsido, and Tyruko to "Agents NOT to be used Concomitantly" table |
4/1/26 | 1/6/26 |
| myprime.com | Interstitial Lung Disease | UPDATE | *Added Jascayd as target agent, with corresponding criteria | 4/1/26 | 1/6/26 |
| myprime.com | Journavx | UPDATE | *Added "moderate to severe" pain to match FDA labeling | 4/1/26 | 1/6/26 |
| myprime.com | Kerendia | UPDATE | *Updated target/prerequisite agent table within criteria to only include 'any product containing a SGLT2' - program is now a single step through SGLT2 regardless of indication *Updated continuation of therapy lookback from 180 days to 90 days *Updated lookback for prerequisites from 180 days to 130 days |
4/1/26 | 1/6/26 |
| myprime.com | Leucovorin | NEW | New implementation | 4/1/26 | 1/6/26 |
| myprime.com | Long Acting Insulin | UPDATE | *Removed cumulative quantity limit setup within the program to align with majority of current client setup, which does not use cumulative quantity limit | 4/1/26 | 1/6/26 |
| myprime.com | Multiple Sclerosis Agents | UPDATE | *Mavenclad: Clarified and condensed the language regarding prior Mavenclad use to require only that the patient has not exceeded the maximum two-course lifetime limit *Mavenclad: Removed monitoring language requiring baseline CBC and lymphocyte counts, aligning with standard practice to exclude warnings/precautions and dosing-related safety parameters from criteria *Mavenclad: Simplified combination-therapy criteria to state that the requested agent will not be used concurrently with another DMT. Sequential transitions (e.g., relapse between Mavenclad courses) are managed within the criteria of the subsequently-requested DMT ("MS Agents other than Mavenclad") rather than within Mavenclad's criteria. *Mavenclad: Changed length of approval to 12 months per the new default approval lengths per regulations *Self-Administered DMTs (excluding Mavenclad): Removed monitoring language requiring LFTs and ECG (related to Aubagio and Gilenya), aligning with standard practice to exclude warnings/precautions and dosing-related safety parameters from criteria *Self-Administered DMTs (excluding Mavenclad): Updated combination-therapy language to remove the qualifier "for the requested indication". DMTs are clearly restricted to monotherapy regardless of indication, consistent with clinical practice guidelines and FDA-labeled use. Additionally, criteria was clarified that sequential treatment following Mavenclad (e.g., relapse occurring between annual Mavenclad courses) is clinically appropriate vs being considered combination therapy. *Both PA modules: Replaced wording of "disease modifying agent (DMA)" to "disease modifying therapy (DMT)" to align with current clinical guidelines treatment terminology *QL: Streamlined QL dosing language by replacing product-specific loading and maintenance dose details with standardized wording directing reviewers to FDA-labeled dosing |
4/1/26 | 1/6/26 |
| myprime.com | Opioids ER | UPDATE | *Added Hysingla ER/hydrocodone ER tabs to Brand/Generic table *Updated approval length for PA and QL to 12 months per state regulation - PS to CSReg |
4/1/26 | 1/6/26 |
| myprime.com | Opioids IR MME | UPDATE | *Added missing criteria "The request does NOT exceed 50 MME per day" to the beginning of the MME without Daily QL module criteria *Updated tapentadol MME conversion factor from 0.4 to 0.3 *Added missing MME conversion factor for oxycodone 10mg tablets |
4/1/26 | 1/6/26 |
| myprime.com | Otezla | UPDATE | 10.15 Ad Hoc *Added weight requirements for Otezla XR for requests for pediatric patients 6 years of age and older for PS and PsA *Updated previous immunomodulator use requirements to exclude sample use and include systemic targeted synthetic small molecule drugs as an option *Added Otezla XR, Rhapsido, and Tyruko to "Agents NOT to be used Concomitantly" table |
4/1/26 | 1/6/26 |
| myprime.com | Parathyroid Hormone Analog for Osteoporosis | UPDATE | Mid-Year *Forteo, Bonsity, Teriparatide non-preferred module- Removed Tymlos from criteria allowing preferred agents to bypass step through requirements |
4/1/26 | 1/6/26 |
| myprime.com | Pseudobulbar Affect | UPDATE | *Removed specialist criteria per contracting *Changed length of approval to the new default approval length per regulations (12 months) |
4/1/26 | 1/6/26 |
| myprime.com | Rapid to Intermediate Acting Insulin | UPDATE | *Removed cumulative quantity limit setup within the program to align with majority of current client setup, which does not use cumulative quantity limit *Added quantity limit amounts to more specific strength/dose (at a GPI 14) to all preferred and non-preferred insulin agents at 100mL/30 days |
4/1/26 | 1/6/26 |
| myprime.com | Rhapsido | NEW | New implementation | 4/1/26 | 1/6/26 |
| myprime.com | Risdiplam | UPDATE | *Updated clinical rationale with new guidelines to confirm add-on therapy is not supported at this time Updated clinical rationale with recommended monitoring duration (6-12 months) before change in therapy is advised which supports length of approval for initial and renewal *Removed "powder for" in dosage form in FDA table to align with prescribing information description |
4/1/26 | 1/6/26 |
| myprime.com | SA Oncology | UPDATE | *Added Phyrago to the brand/generic table to require step through generic dasatinib *Decreased QLs for 3 strengths of Cometriq to match how the manufacturer packages the blister packs in boxes for 28 days supply |
4/1/26 | 1/6/26 |
| myprime.com | Tezspire | UPDATE | *Added example of 'asthma control therapy' to uncontrolled asthma requirement wording for clarity *Added additional requirement/pathway for asthma to allow a bypass of uncontrolled asthma requirements (within the past 12 months) if the patient was treated with a biologic immunomodulator for asthma within the past 12 months since biologic agents (e.g., Dupixent, Nucala) have been shown to decrease exacerbations. Treatment on samples is not approvable. *Added CRSwNP diagnosis specific requirements: two symptoms of CRS, CRS symptoms for at least 12 weeks, diagnosis confirmation testing, step through intranasal corticosteroid prerequisite. *Updated concurrent inhaled corticosteroid (ICS) requirements to include the scenario that a patient is currently treated with a biologic immunomodulator other than the requested agent. *Added concurrent therapy with standard nasal polyp maintenance therapy for CRSwNP (Initial and Renewal) *Updated specialist listing to include examples for CRSwNP *Changed length of approval to the new default approval length per regulations (12 months) *(Renewal): Removed specific improvement/stability (clinical benefit) requirements for asthma and standardized the clinical benefit requirement; no specific examples/instructions are listed in FDA labeling. *Added Otezla XR, Rhapsido, and Tyruko to "Agents NOT to be used Concomitantly" table |
4/1/26 | 1/6/26 |
| myprime.com | Thrombopoietin Receptor Agonists, Tavalisse and Wayrilz | UPDATE | *Revised concomitant use not allowed criteria to specifically exclude combined use of more than one tyrosine kinase inhibitors together OR combined use of one or more thrombopoietin receptor agonists together | 4/1/26 | 1/6/26 |
| myprime.com | TIRF | UPDATE | *Updated approval length for PA and QL to 12 months per state regulation | 4/1/26 | 1/6/26 |
| myprime.com | Urea Cycle Disorders | UPDATE | *Added age verification criteria, due to restriction of Olpruva's indication | 4/1/26 | 1/6/26 |
| myprime.com | VMAT2 Inhibitors | UPDATE | *Added Continuation of Therapy criteria as the indications for the target agents are chronic/non-curative *Standardized Continuation of Therapy to allow members already on therapy to bypass additional PA requirements (e.g., age criteria) and grouped age criteria with only the FDA labeled indications *Removed the Xenazine/tetrabenazine section since all targets are FDA labeled for chorea associated with Huntington's disease and condensed the criteria for approvable indications *Rearranged criteria for tardive dyskinesia to lead with indication instead of the requested agent - no change to clinical intent *Removed "for the requested indication" from criteria disallowing concomitant use with another VMAT2 inhibitor to align with FDA labeled contraindications for all target agents *Changed length of approval to the new default approval lengths per regulations (12 months) |
4/1/26 | 1/6/26 |
| myprime.com | Xolair | UPDATE | *Asthma: Updated pretreatment IgE level and weight requirements to be "If the patient" to assist in appropriate question set building and allow a pathway for patients less than 6 years old. *Asthma: Added example of 'asthma control therapy' to uncontrolled asthma requirement wording for clarity *Asthma: Added additional requirement/pathway for asthma to allow a bypass of uncontrolled asthma requirements (within the past 12 months) if the patient was treated with a biologic immunomodulator for asthma within the past 12 months since biologic agents (e.g., Dupixent, Xolair) have been shown to decrease exacerbations. Treatment on samples is not approvable. *CSU: Updated requirement assessing if the patient is currently treated with medication known to cause or worsen urticaria to be a singular requirement and to be attestation. *CSU: Moved 2-week duration requirement to the trial of a second-generation H1-antihistamine titrated up to 4 times above the FDA maximum dose based on guideline treatment algorithm *CSU: Updated wording of second-generation H1-antihistamine trial requirements for clarity and to capture desired intent *CRSwNP: Updated confirmation test to state "nasal" endoscopy and moved each test to its own line for clarity *Asthma: Updated concurrent inhaled corticosteroid (ICS) requirements to include the scenario that a patient is currently treated with a biologic immunomodulator other than the requested agent. *CSU: Added required concomitant therapy with a second-generation H1-antihistamine based on guidelines, clinical trials, and competitive analysis (Initial and Renewal). Set up Renewal requirement to be future facing/attestation. *Updated specialist requirement by adding specific examples for each indication *Changed length of approval to the new default approval length per regulations (12 months) *(Renewal): Removed specific improvement/stability (clinical benefit) requirements for asthma and standardized the clinical benefit requirement; no specific examples/instructions are listed in FDA labeling. *Added Otezla XR, Rhapsido, and Tyruko to "Agents NOT to be used Concomitantly" table |
4/1/26 | 1/6/26 |
| myprime.com | Zeposia | UPDATE | *Movement of Rinvoq to Step 2 in Immunomodulator Agents Step table *Updated previous immunomodulator use requirement to exclude sample use and include systemic targeted synthetic small molecule drugs as an option *Replaced wording of "disease modifying agent" to "disease modifying therapy" to align with current clinical guidelines treatment terminology *Revised combination therapy criteria. Zeposia is not clinically supported as concurrent use with another DMT, but sequential use post-Mavenclad is clinically supported. *Aligned the UC language with the existing wording in the Biologic Immunomodulators policy to ensure consistency in criteria language and application across programs |
4/1/26 | 1/6/26 |
| 12.01.089 | Harliku | NEW | Implementation of NEW guidelines. | 4/1/26 | 1/5/26 |
| 12.01.090 | Brensocatib | NEW | Implementation of NEW guidelines. | 4/1/26 | 1/5/26 |
| 12.01.091 | Leucovorin | NEW | Implementation of NEW guidelines. | 4/1/26 | 1/5/26 |
| 12.01.092 | Rhapsido | NEW | Implementation of NEW guidelines. | 4/1/26 | 1/5/26 |
| 12.01.093 | Injectable and Health Care Administered Oncology | NEW | Implementation of NEW guidelines. | 3/9/26 | 1/5/26 |
| 05.01.051 | Tumor-Infiltrating Lymphocytes for Advanced Melanoma | NEW | Implementation of NEW guidelines. | 3/2/26 | 12/29/25 |
| 12.01.007 | Cyramza | DELETE | Archiving the criteria. | 3/9/26 | 1/5/26 |
| 12.01.027 | Abraxane | DELETE | Archiving the criteria. | 3/9/26 | 1/5/26 |
| 12.01.028 | Adcentris | DELETE | Archiving the criteria. | 3/9/26 | 1/5/26 |
| 12.01.029 | Alimta | DELETE | Archiving the criteria. | 3/9/26 | 1/5/26 |
| 12.01.030 | Arzerra Gazyva - Arzerra, Gazyva | DELETE | Archiving the criteria. | 3/9/26 | 1/5/26 |
| 12.01.034 | Herceptin | DELETE | Archiving the criteria. | 3/9/26 | 1/5/26 |
| 12.01.035 | Kadcyla | DELETE | Archiving the criteria. | 3/9/26 | 1/5/26 |
| 12.01.036 | Kyprolis | DELETE | Archiving the criteria. | 3/9/26 | 1/5/26 |
| 12.01.037 | Perjeta | DELETE | Archiving the criteria. | 3/9/26 | 1/5/26 |
| 12.01.040 | Vectibix | DELETE | Archiving the criteria. | 3/9/26 | 1/5/26 |
| 12.01.041 | Zaltrap | DELETE | Archiving the criteria. | 3/9/26 | 1/5/26 |
| 12.01.042 | Oncology Immunotherapy | UPDATE | Clinical evidence to support the policy position was updated. There is no change to the policy position statement listed. | 3/2/26 | 12/29/25 |
| 02.04.107 | Carrier Screening for Genetic Diseases | UPDATE | Added procedure code 96041 for genetic counseling. | 3/2/26 | 12/29/25 |
| 02.04.117 | Genetic Testing for Mitochondrial Disorders | UPDATE | Clinical evidence to support the policy position was updated & references added to background section only. There is no change to the policy position statement listed. | 3/2/26 | 12/29/25 |
| 02.04.153 | Tumor-Informed Circulating Tumor DNA Testing for Cancer Management | UPDATE | Clinical evidence to support the policy position was updated & references added. There is no change to the policy position statement listed. | 3/2/26 | 12/29/25 |
| 02.04.155 | Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Prostate Cancer (BRCA1/2, Homologous Recombination Repair Gene Alterations, NTRK Gene Fusion) | NEW | Implementation of NEW guidelines. | 3/2/26 | 12/29/25 |
| 02.04.156 | Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Ovarian Cancer (BRCA1, BRCA2, Homologous Recombination Deficiency, NTRK) | NEW | Implementation of NEW guidelines. | 3/2/26 | 12/29/25 |
| 06.01.03 | Computed Tomography to Detect Coronary Artery Calcification | UPDATE | Clinical evidence to support the policy position was updated & references added. There is no change to the policy position statement listed. | 3/2/26 | 12/29/25 |
| 07.01.158 | Balloon Dilation of the Eustachian Tube | UPDATE | Clinical evidence to support the policy position was updated. There is no change to the policy position statement listed. | 3/2/26 | 12/29/25 |
| 07.01.75 | Cryosurgical Ablation of Primary or Metastatic Liver Tumors | UPDATE | Clinical evidence to support the policy position was updated, references added and guidelines updated. There is no change to the policy position statement listed. | 3/2/26 | 12/29/25 |
| 07.01.95 | Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors | UPDATE | Clinical evidence to support the policy position was updated & references added. There is no change to the policy position statement listed. | 3/2/26 | 12/29/25 |
| 07.03.02 | Allogeneic Pancreas Transplant | UPDATE | Clinical evidence to support the policy position was updated. There is no change to the policy position statement listed. | 3/2/26 | 12/29/25 |
| 07.03.04 | Isolated Small Bowel Transplant | UPDATE | Clinical evidence to support the policy position was updated. There is no change to the policy position statement listed. | 3/2/26 | 12/29/25 |
| 07.03.05 | Small Bowel/Liver and Multivisceral Transplant | UPDATE | Clinical evidence to support the policy position was updated. There is no change to the policy position statement listed. | 3/2/26 | 12/29/25 |
| 07.03.06 | Liver Transplant and Combined Liver-Kidney Transplant | UPDATE | Policy position statement updated: added bullet points for neuroendocrine tumors metastatic to the liver and intrahepatic cholangiocarcinoma in the investigational policy statement. Also added 'however, the study was limited by the small sample size and heterogeneous standard of care' in the summary of evidence for unresectable colorectal liver metastases. | 3/2/26 | 12/29/25 |
| 07.03.07 | Lung and Lobar Lung Transplant | UPDATE | Clinical evidence to support the policy position was updated & references added. There is no change to the policy position statement listed. | 3/2/26 | 12/29/25 |
| 07.03.08 | Heart/Lung Transplant | UPDATE | Clinical evidence to support the policy position was updated & references added. There is no change to the policy position statement listed. | 3/2/26 | 12/29/25 |
| 07.03.09 | Heart Transplant | UPDATE | Clinical evidence to support the policy position was updated & references added. There is no change to the policy position statement listed. | 3/2/26 | 12/29/25 |
| 07.03.12 | Islet Transplantation for Chronic Pancreatitis and Donislecel-jujn for Type 1 Diabetes | UPDATE | Clinical evidence to support the policy position was updated & references added. There is no change to the policy position statement listed. | 3/2/26 | 12/29/25 |
| 07.03.13 | Composite Tissue Allotransplantation of the Hand and Face | UPDATE | Clinical evidence to support the policy position was updated & references added. There is no change to the policy position statement listed. | 3/2/26 | 12/29/25 |
| 08.01.52 | Orthopedic Applications of Stem Cell Therapy (Including Allografts and Bone Substitutes Used With Autologous Bone Marrow) | UPDATE | Clinical evidence to support the policy position was updated & references added. Clinical evidence for Trinity Elite cellular bone allograft in joint fusion procedures has been added. There is no change to the policy position statement listed. | 3/2/26 | 12/29/25 |
| 08.01.61 | Focal Treatments for Prostate Cancer | UPDATE | Clinical evidence to support the policy position was updated & references added. There is no change to the policy position statement listed. | 3/2/26 | 12/29/25 |
| 08.01.68 | Omidubicel as Adjunct Treatment for Hematologic Malignancies | UPDATE | Clinical evidence to support the policy position was updated & references added. There is no change to the policy position statement listed. | 3/2/26 | 12/29/25 |
| 12.01.038 | Provenge | UPDATE | Updated policy information, including updated policy position information. | 2/23/26 | 12/22/25 |
| 12.01.047 | Soliris | UPDATE | Updated policy information, including updated policy position information. | 2/23/26 | 12/22/25 |
| 12.01.049 | Spinraza | UPDATE | Updated policy information, including updated policy position information. | 2/23/26 | 12/22/25 |
| 02.04.060 | JAK2, MPL, and CALR Testing for Myeloproliferative Neoplasms | UPDATE | Clinical evidence to support the policy position was updated. Minor editorial refinements to policy statements; intent unchanged. | 2/23/26 | 12/22/25 |
| 02.04.061 | Gene Expression Profile Testing and Circulating Tumor DNA Testing for Predicting Recurrence in Colon Cancer | UPDATE | Clinical evidence to support the policy position was updated. There is no change to the policy position statement listed. | 2/23/26 | 12/22/25 |
| 02.04.078 | Molecular Markers in Fine Needle Aspiration of the Thyroid | UPDATE | Clinical evidence to support the policy position was updated and references added. RosettaGX test removed from policy as the test has been discontinued. Policy statements unchanged. | 2/23/26 | 12/22/25 |
| 04.01.018 | Ovarian and Internal Iliac Vein Endovascular Occlusion as a Treatment of Pelvic Congestion Syndrome | UPDATE | Clinical evidence to support the policy position was updated. There is no change to the policy position statement listed. | 2/23/26 | 12/22/25 |
| 04.02.005 | Preimplantation Genetic Testing | UPDATE | Clinical evidence to support the policy position was updated. There is no change to the policy position statement listed. | 2/23/26 | 12/22/25 |
| 07.01.102 | Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux | UPDATE | Clinical evidence to support the policy position was updated. There is no change to the policy position statement listed. | 2/23/26 | 12/22/25 |
| 07.03.001 | Kidney Transplant | UPDATE | Clinical evidence to support the policy position was updated. There is no change to the policy position statement listed. | 2/23/26 | 12/22/25 |
| 02.04.051 | Genotype-Guided Tamoxifen Treatment | DELETE | Archiving the criteria. | 2/16/26 | 12/15/25 |
| 02.04.052 | Molecular Testing for the Management of Pancreatic Cysts and Solid Pancreaticobiliary Lesions | DELETE | Archiving the criteria. | 2/16/26 | 12/15/25 |
| 08.01.014 | Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds | DELETE | Archiving the criteria. | 2/16/26 | 12/15/25 |
| 08.01.045 | Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas or Metastasis to the Brain | DELETE | Archiving the criteria. | 2/16/26 | 12/15/25 |
| 01.01.015 | Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions | DELETE | Archiving the criteria. | 2/16/26 | 12/15/25 |
| 01.01.017 | Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence | DELETE | Archiving the criteria. | 2/16/26 | 12/15/25 |
| 02.04.002 | Germline Genetic Testing for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers (BRCA1, BRCA2, PALB2) | UPDATE | Clinical evidence to support the policy position was updated and references added. There is no change to the policy position statement listed. Added new dx codes for family and personal history of fallopian tubes eff 10/1/25 and added 96041 for genetic counseling. | 2/16/26 | 12/15/25 |
| 02.04.108 | Noninvasive Fetal RHD Genotyping Using Cell-Free Fetal DNA | UPDATE | Clinical evidence to support the policy position was updated. There is no change to the policy position statement listed. | 2/16/26 | 12/15/25 |
| 02.04.116 | Invasive Prenatal (Fetal) Diagnostic Testing | UPDATE | Clinical evidence to support the policy position was updated. There is no change to the policy position statement listed. | 2/16/26 | 12/15/25 |
| 02.04.122 | Chromosomal Microarray Testing for the Evaluation of Pregnancy Loss | UPDATE | Clinical evidence to support the policy position was updated. There is no change to the policy position statement listed. | 2/16/26 | 12/15/25 |
| 02.04.126 | Germline Genetic Testing for Gene Variants Associated With Breast Cancer in Individuals at High Breast Cancer Risk (CHEK2, ATM, and BARD1) | UPDATE | Clinical evidence to support the policy position was updated. There is no change to the policy position statement listed. Code 0131U will deleted effective 12/31/2025 | 2/16/26 | 12/15/25 |
| 02.04.149 | Molecular Testing for Germline Variants Associated with Ovarian Cancer (BRIP1, RAD51C, RAD51D, NBN) | UPDATE | Clinical evidence to support the policy position was updated. There is no change to the policy position statement listed. Diagnosis code Z80.44 added effective 10/1/2025; Codes 0131U, 0132U, 0135U will be deleted effective 12/31/2025. | 2/16/26 | 12/15/25 |
| 02.04.154 | Germline Genetic Testing for Hereditary Diffuse Gastric Cancer (CDH1, CTNNA1) | UPDATE | Clinical evidence to support the policy position was updated. There is no change to the policy position statement listed. | 2/16/26 | 12/15/25 |
| 02.04.032 | Measurement of Lipoprotein-Associated Phospholipase A2 in the Assessment of Cardiovascular Risk | DELETE | Archiving the criteria. | 2/9/26 | 12/8/25 |
| 07.01.072 | Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, Biacuplasty and Intraosseous Basivertebral Nerve Ablation | DELETE | Archiving the criteria. | 2/9/26 | 12/8/25 |
| 02.04.065 | Biomarker Testing in Risk Assessment and Management of Cardiovascular Disease | UPDATE | Clinical evidence to support the policy position was updated. There is no change to the policy position statement listed. | 2/9/26 | 12/8/25 |
| 02.04.077 | Somatic Genetic Testing to Select Individuals with Melanoma or Glioma for Targeted Therapy (BRAF, NTRK, IDH1, IDH2) | UPDATE | Clinical evidence to support the policy position was updated and references added. New indication and MN policy statements added for IDH1 and IDH2 testing in glioma. New indication, evidence review, and MN policy statements added for BRAF variant and BRAF gene fusion rearrangement testing for tovorafenib treatment selection in recurrent or refractory pediatric low-grade glioma. | 2/2/26 | 12/1/25 |
| 08.01.033 | High-Dose Rate Temporary Prostate Brachytherapy | DELETE | Archiving the criteria. | 2/2/26 | 12/1/25 |
| 12.01.031 | Bevacizumab - Alymsys, Avastin, Mvasi, Vegzelma, Zirabev | UPDATE | Updated policy information, including updetd policy position information. Added preferred product and biosimilar information. The preferred products are: Mvasi and Zirabev. | 1/1/26 | 10/28/25 |
| 12.01.039 | Rituxan Oncology - Rituxan Hycela | UPDATE | Updated policy information, including updetd policy position information. Added preferred product and biosimilar information. The preferred products are: Ruxience, Truxima, and Riabni. | 1/1/26 | 10/28/25 |
| 12.01.018 | Infusible Biologic Immunomodulator - Actemra®, Avsola®, Cimzia® , Cosentyx®, Entyvio®, Ilumya®, Inflectra®, Omvoh®, Orencia®, Otulfi™, Pyzchiva®, Remicade®, Infliximab, Renflexis®, Selarsdi™ Simponi ARIA®, Skyrizi®, Stelara®, Steqeyma®, Taltz®, Tofidence™, Tremfya®, Tyenne®, Wezlana™, Yesintek™ | UPDATE | Updated policy information, including updetd policy position information. Added preferred product and biosimilar information. The preferred products for Infliximab are: Avsola and Inflectra. The preferred products for Ustekinumab are: Selarsdi, Yesintek, and Stegqeyma. | 1/1/26 | 10/28/25 |
| 12.01.052 | Viscosupplements - Durolane, Euflexxa, Gel-One, GELSYN-3, GenVisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz, Supartz FX, Synvisc, Synvisc-One, Visco-3 | UPDATE | Updated policy information, including updetd policy position information. Added preferred product and biosimilar information. The preferred products are: Durolane, Gelsyn-3, Supartz, Visco-3, and Gel-One. | 1/1/26 | 10/28/25 |
| 12.01.009 | Prolia - Osteoporosis | UPDATE | Updated policy information, including updetd policy position information. Added preferred product and biosimilar information. The preferred products are: Jubbonti and Stobclo. | 1/1/26 | 10/28/25 |
| 12.01.016 | Immune Globulins - Bivigam 10%, Carimune NF, Flebogamma 5% DIF, Flebogamma 10% DIF, Gammagard S/D, Gammaplex 5%, Gammaplex 10%, Octagam 5%, Octagam 10%, Prigiven 10%, Gamunex-C 10%, Gammaked 10%, Gammagard Liquid, Hizentra, Hyqvia, Cuvitru 20%, Gamastan S/D 15-18% | UPDATE | Updated policy information, including updetd policy position information. Added preferred product and biosimilar information. The preferred products for Immune Globulins IV are: Octagam, Ganmaked/Gamunix-C, Gammagard and Privgen. The preferred products for Immune Globulins SC are: Hyqvia, Hizentra, Xembify, and Cutaquig. | 1/1/26 | 10/28/25 |
| myprime.com | Androgens and Anabolic Steroids | UPDATE | *Removed Androderm [GPI-12: 231000300085] as a Target Agent in the program. Obsolete as of 01/26/2025. *Added "Testosterone gel" to list of Target Agents in requirement 1.A for clarity; no change to intent. *Updated requirement wording to state "16 years of age or older" instead of "or over" for clarity; no change to intent. *'PA with QL-Through Generic' module: Specified that FDA labeling and compendia (AHFS, DrugDex 1 or 2a level of evidence, or NCCN 1 or 2a recommended use) are allowable to determine if a generic androgen or anabolic steroid is supported for the requested indication. *Added Note for Operations to have question help text added to questions involving the step through generic for the 'PA with QL-Through Generic' module to assist reviewers with assessing supported indications. |
1/1/26 | 10/24/25 |
| myprime.com | Antifungals | UPDATE | *Removed obsolete target: Cresemba (GPI 114070301021) from PA targets. *Brexafemme: rearranged the criteria to lead with the diagnosis of vulvovaginal candidiasis (VVC) instead of the age/post menarchal pediatric female to help downstream Clinical Ops with the build and denial wording; no change to intent. *Cresemba, Noxafil: updated the generic name for Cresemba to match prescribing information instead of how IDSA guidelines refers to this drug. *Cresemba: added age criteria since this target has FDA labeled age limitations. *Noxafil: updated criteria for current and new indications. *Noxafil, Vfend: removed specific renewal requirements for a diagnosis of prophylaxis against invasive aspergillus as initial requirements are broader than just being severely immunocompromised and can be assessed with the general nonspecific diagnosis criteria to support continued use. *Vfend: moved the age criteria up so that is only applies to FDA labeled indications (not prophylaxis against invasive aspergillosis). *Vfend: removed diagnosis of prophylaxis against Candida infection due to lack of FDA labeling or clear/specific guidelines to support this indication. *Vfend: added criteria to the diagnosis of prophylaxis against aspergillosis from current IDSA guidelines for the diagnosis and management of aspergillosis. |
1/1/26 | 10/24/25 |
| myprime.com | Biologic Immunoodulator OP2 | UPDATE | ****Wyoming is removing Stelara as preferred**** *QL Target Agent: Updated Bimzlex 320 mg/2mL QL to 1 pen/syringe per 56 days (previously 1 pen/syringe per 28 days). This was done to prevent the utilization of 320mg every 4 weeks for psoriasis (patients <120 kg) without a QL authorization. *Removed anthralin as an allowable/required prerequisite for psoriasis. *Crohn's disease: Based on the new ACG 2025 guideline (in addition to the AGA guideline), an additional pathway was added to not require T/F a conventional agent if the patient has severely active Crohn's disease. This update mirrors how we have UC requirements set up. *IV induction requirements: Added additional pathway to not require that the patient has (or will) receive an IV product for induction therapy if the patient is already established on subcutaneous therapy with the active drug for the requested indication and IV induction therapy is no longer clinically appropriate. *Step Table (Simponi for UC): Removed note requiring T/F of an adalimumab product. Will now allow/accept previous T/F of any of the Step 1 agents. *Added "as maintenance dosing" to Tremfya 200 mg requirement for clarity. The 200mg may be used for some loading dose regimens, but the intent of the requirement is to confirm the 200 mg strength being used for maintenance therapy is only for Crohn's disease or ulcerative colitis. *Added Starjemza to "Agents NOT to be used Concomitantly" table. *Removed Tremfya IV induction dosing for ulcerative colitis (UC) requirements. Based on updated FDA labeling (9/19/25) the subcutaneous dosage form may be used for induction dosing for UC. *Added Tremfya weight requirement for pediatric patients for a diagnosis of plaque psoriasis or psoriatic arthritis. FDA labeling requires pediatric patients to weigh 40 kg or greater. |
1/1/26 | 10/24/25 |
| myprime.com | CGRP | UPDATE | *Standardized Continuation of Therapy (COT) to allow members already on therapy to bypass additional PA requirements (e.g., age, diagnostics). *Addition of requested agent and strength check to confirm FDA labeled for migraine prophylaxis in COT pathway. *Standardized wording for "the requested agent is a non-preferred agent" in preferred agent criteria. *Addition of “triptan combination agents” to step requirement of acute migraine therapy criteria per trade. Request was to decrease appearance of disadvantaging one agent over the other by not having the prerequisites exactly the same in CGRP and acute migraine PAQLs. *Removed medication overuse headache criteria per updated literature, guidelines, that do not support CGRP agents contributing to MOH. *Addition of weight and age check for Ajovy per new indication and labeling under episodic migraine criteria in initial and renewal criteria. |
1/1/26 | 10/24/25 |
| myprime.com | Constipation Agents | UPDATE | *Added Linzess as non-preferred. *Added the diagnosis of pediatric functional constipation. *Added lubiprostone (MSC Y) as a preferred agent. *Removed Linzess as for active cancer pain as NCCN no longer supports this specific agent for this diagnosis and other agents can be used. |
1/1/26 | 10/24/25 |
| myprime.com | Continuous Glucose Monitor | UPDATE | *Updated quantity limit for Freestyle Libre Plus 2 and 3 to 2 sensors/30 days. Each sensor is used every 15 days. | 1/1/26 | 10/24/25 |
| myprime.com | Copay Waiver ACA Prevention | UPDATE | *Added Yeztugo (lenacapavir) to HIV PrEP criteria as an allowable agent for ACA waiver copay requirements. | 1/1/26 | 10/24/25 |
| myprime.com | Corticotropin | UPDATE | *Removal of Acthar gel pen-injector (GPI 3030001000D1**). Removed as target since not approved for use in infantile spasms per prescribing information | 1/1/26 | 10/24/25 |
| myprime.com | Coverage Exception | UPDATE | *Changed 'contraception' to 'contraceptive' within criteria question, "The requested agent is a contraception agent AND BOTH of the following:" to remain consistent with language in PS FE program; no change to intent. *Edited HIV PrEP and iron ACA sections within criteria that mirror updates made in the ACA copay waiver program to keep programs consistent. *Changed "BOTH" to "ALL" within formulary alternative related criteria question since adding biosimilar language increased the number of pathways from two to three. *Added "(one agent may satisfy multiple requirements below)" to the end of the criteria question, "The requested agent has formulary alternatives (any formulary tier) for the diagnosis being treated by the requested agent AND ALL of the following" for member/patient transparency surrounding overall number of formulary alternative required to meet criteria; no change to intent. *Added "that is NOT expected to occur with requested brand agent" to generic equivalent step language in criteria. *Introduced biosimilar language in step requirement of criteria to be consistent with other programs assessing biosimilar usage. *Added Yeztugo (lenacapavir) to HIV PrEP criteria as an allowable agent for ACA waiver copay requirements. *Added '(starting with samples is not approvable)' to CoT criteria question. |
1/1/26 | 10/24/25 |
| myprime.com | Crenessity | UPDATE | *Removed "due to 21-hydroxylase deficiency" from the diagnosis requirement to match the FDA labeled indication of "with classic congenital adrenal hyperplasia (CAH)". | 1/1/26 | 10/24/25 |
| myprime.com | Dojolvi | UPDATE | *Removed "at least" from the criteria that lists disease confirmation pathways. | 1/1/26 | 10/24/25 |
| myprime.com | Empaveli | UPDATE | *New criteria added for expanded indications - Treatment of adult and pediatric patients aged 12 years and older with C3 glomerulopathy (C3G) or primary immune-complex membranoproliferative glomerulonephritis (IC-MPGN), to reduce proteinuria. *Added diagnosis check for QL with PA module to only allow requests over QL for PNH diagnosis. |
1/1/26 | 10/24/25 |
| myprime.com | Enspryng | UPDATE | *Removed "for the requested indication" in concomitant use to not allow cross indication use. | 1/1/26 | 10/24/25 |
| myprime.com | Fabhalta | UPDATE | *Added supporting statement for disallowance of concomitant therapy across indications. | 1/1/26 | 10/24/25 |
| myprime.com | Filsuvez | UPDATE | *Moved/indented FDA age requirement to bypass continuation of therapy (COT). | 1/1/26 | 10/24/25 |
| myprime.com | Growth Hormone | UPDATE | *Updated ALL step therapy criteria to require contraindication to ALL preferred agents to be consistent with Prime Standard. | 1/1/26 | 10/24/25 |
| myprime.com | Hepatitis C Direct Acting Antivirals | UPDATE | *Mavyret module only, clarified pathway for acute vs chronic hepatitis C treatment within the simplified treatment requirements. | 1/1/26 | 10/24/25 |
| myprime.com | Hyftor | UPDATE | *To criteria requiring 3 or more facial angiofibromas, added "at least 2mm in diameter with redness in each", to reflect inclusion criteria in the clinical trial. | 1/1/26 | 10/24/25 |
| myprime.com | IL-4 Inhibitors | UPDATE | *Updated wording of previous biologic use requirement to bypass conventional agent use from "another" to "a" based on request from physician reviewer team. If a patient has a medication history of use with the requested agent, we should also accept that to not require a step-back to conventional agent use; in addition to other biologic agents. *Added Bullous Pemphigoid disease specific requirements based on guidelines and Dupixent clinical trials. *Removed post-bronchodilator FEV1 and chronic bronchitis for 3 months requirements for COPD to have Dupixent requirements at parity with Nucala. *Added additional requirement/pathway for COPD to allow a bypass of exacerbations within the past 12 months if the patient was treated with a biologic immunomodulator for COPD within the past 12 months since biologic agents (e.g., Dupixent, Nucala) have been shown to decrease exacerbations; treatment on samples is not approvable. *Added bullous pemphigoid requirements for concomitant therapy with a tapering course of an oral corticosteroid started at a dose of at least 0.5 mg prednisone/kg/day (or an equivalent). Includes pathway to not require if the patient has an intolerance, hypersensitivity, or contraindication to all oral corticosteroids, and a pathway to not require if the patient is currently treated with Dupixent and has already tapered off of oral corticosteroids. *Added Starjemza to "Agents NOT to be used Concomitantly" table. |
1/1/26 | 10/24/25 |
| myprime.com | IL-5 Inhibitors | UPDATE | *Added COPD disease specific requirements to support the new FDA labeled indication for Nucala. *Added Starjemza to "Agents NOT to be used Concomitantly" table. |
1/1/26 | 10/24/25 |
| myprime.com | Isturisa | UPDATE | *Removed requirement that patient's Cushing's syndrome diagnosis was confirmed persistent or recurrent. It can be inferred that a patient's diagnosis was confirmed. | 1/1/26 | 10/24/25 |
| myprime.com | Korlym | UPDATE | *Added option for another FDA labeled indication and adjusted outline to accommodate this addition. | 1/1/26 | 10/24/25 |
| myprime.com | Lyrica and Savella | UPDATE | *Update to quantity limit target Savella titration pack. | 1/1/26 | 10/24/25 |
| myprime.com | Myalept | UPDATE | *Removed leptin deficiency "diagnosis" and added "confirmed by laboratory testing (i.e., less than 12 ng/mL)" requirement. *Updated the exclusion disease state requirements to include the wording, limitations for use as they are listed in the PI. |
1/1/26 | 10/24/25 |
| myprime.com | Niemann Pick Disease Type C Agents | UPDATE | *Added disallowance of concurrent use with another NPC agent. *Added "loss of motor function, difficulty swallowing, speech impairment, cognitive impairment" as examples of neurological symptoms. |
1/1/26 | 10/24/25 |
| myprime.com | Opzelura | UPDATE | *Removed BSA requirement for atopic dermatitis to align requirements with Vtama and Zoryve programs. *Removed separation of distinct prerequisite step through agents allowed/required based on area(s) of the body vitiligo is impacting. *Updated/added 12-week duration of therapy to vitiligo prerequisite trial (both TCS or TCI). *Added Starjemza to "Agents NOT to be used Concomitantly" table. |
1/1/26 | 10/24/25 |
| myprime.com | Oral Inhalers | UPDATE | *Added the branded generic for Arnuity (Fluticasone furoate ellipta) to the target agents and to the targets in the Step table per contracting. | 1/1/26 | 10/24/25 |
| myprime.com | Oral Teracycline Derivates | UPDATE | *Doxycycline monohydrate capsules (50mg & 100mg ONLY) updated to be Prerequisites; 75mg and 150mg capsules will remain as Target Agents. *Doxycycline hyclate tablet (50 mg, 75 mg, 150 mg ONLY) updated to be Targets. *Doxycycline delayed release 40 mg (Rosacea generic) updated to be Target. *Minocycline HCl (75 mg and 100 mg ONLY) updated to be Targets; 50 mg tablets updated to be Prerequisite. *Removed Minolira (105 mg and 135 mg minocycline hydrochloride extended release tablet) from the program due to going obsolete 5/31/25. |
1/1/26 | 10/24/25 |
| myprime.com | Otezla | UPDATE | *Added weight requirement (20 kg or greater) for pediatric patients 6 years of age and older with active psoriatic arthritis due to new FDA labeled indication. *Removed anthralin as an allowable/required prerequisite for psoriasis. *Added Starjemza to "Agents NOT to be used Concomitantly" table. |
1/1/26 | 10/24/25 |
| myprime.com | Oxybates | UPDATE | *Removed limitation for concomitant therapy. | 1/1/26 | 10/24/25 |
| myprime.com | Parathyroid Hormone Analog for Osteoporosis | UPDATE | *Forteo, Bonsity, Teriparatide module- Added Bonsity and brand Teriparatide to require Forteo generic equivalent step through. | 1/1/26 | 10/24/25 |
| myprime.com | PCSK9 Inhibitors | UPDATE | *Updated criteria for Repatha to remove the need to use Repatha in combination with other lipid lowering therapies due to update in prescribing information. *Aligned language for all 10-year ASCVD risk criteria to "a maximally tolerated statin" for consistency. *Removed from HoFH criteria the need for concomitant use with other lipid-lowering therapies to reflect recent FDA labeling update to Repatha indications in initial and renewal sections. *Removed the word "primary" before indication of hyperlipidemia to reflect FDA labeling update to Repatha indications. *Removed "or calcification" from Coronary Artery Calcium (CAC). |
1/1/26 | 10/24/25 |
| myprime.com | Phenylketonuria | UPDATE | *Updated phenylalanine blood level criteria to a universal value of greater than 360 micromol/L for all patients, due to new ACMG guidelines. *Added "Sephience" in criteria where appropriate (i.e., "patient has baseline blood Phe level greater than 360", disallowance of concurrent use with another target). *Removed lab value conversions of "mg/dL" as these are no longer referenced in newer PKU guidelines. *Standardized criteria that disallows concurrent use with another PKU agent. *Standardized renewal clinical benefit check (removed specific parameters of efficacy that are not part of labeled indication). |
1/1/26 | 10/24/25 |
| myprime.com | Phosphate Binders | UPDATE | *QL revised from only a 90-day supply allowed per year at MDD TO 30-day supplies at MDD up to 12 months. *Removed “patient is NOT receiving dialysis” requirement from QL criteria. *Changes are due to certain states allowing longer commercial coverage timeframe for dialysis patients before they are required to move over to ESRD bundle coverage. |
1/1/26 | 10/24/25 |
| myprime.com | Progesterones | UPDATE | *Split double step for Crinone 8% into two single steps to better follow the use of standardization language from template and moved preferred agent identification into table. | 1/1/26 | 10/24/25 |
| myprime.com | PPI | UPDATE | *Prilosec 2.5 mg Susp Packet quantity limit increased from 1/day to 2/day per strategy to allow dosing within FDA labeling. | 1/1/26 | 10/24/25 |
| myprime.com | Pulmonary Arterial Hypertension | UPDATE | *Changed "triple" to "quadruple" within quadruple therapy section under PAH diagnosis related to prostanoid use. *Removed obsolete strength 32mcg/48mcg of Tyvaso dpi maintenance kit. *Adjusted standard age criteria within the outline to allow bypass for COT patients. |
1/1/26 | 10/24/25 |
| myprime.com | Recorlev | UPDATE | *Removed requirement that patient's Cushing's syndrome diagnosis was confirmed persistent or recurrent. It can be inferred that a patient's diagnosis was confirmed. | 1/1/26 | 10/24/25 |
| myprime.com | Resmetirom | UPDATE | *Updated the FIB-4 requirement so that it will not be required but a one of two option. *Addition of medical records wording to BMI. |
1/1/26 | 10/24/25 |
| myprime.com | Retinoids | UPDATE | *Removed Cabtreo as a Target Agent in this program. Moving to Topical Antibiotics and Combinations ST program. *Added "that is NOT expected to occur with the requested agent" on intolerance/hypersensitivity and CI prerequisite requirements due to overlapping active drugs. |
1/1/26 | 10/24/25 |
| myprime.com | SA Oncology | UPDATE | *Addition of Danziten, Nilotinib d-tartrate, and nilotinib (generic for Tasigna) to non-preferred agents for newly diagnosed Ph+CML in chronic phase alongside brand Tasigna per contracting. *Addition of Ibtrozi to non-preferred agents along with Augtyro for metastatic ROS1-positive non-small cell lung cancer per contracting. *Addition to Brand/Generic Equivalent table: Revlimid (lenalidomide) per trade as contracts limiting the generic lenalidomide supply in the market will expire 1/1/26. *Removal from the Brand/Generic Equivalent table: Temodar (temozolomide) as this agent is only available as a generic. |
1/1/26 | 10/24/25 |
| myprime.com | Sohonos | UPDATE | *Updated day supply for all strengths of Sohonos to 28-day supply. | 1/1/26 | 10/24/25 |
| myprime.com | Sucraid | UPDATE | *Added the standard age criteria as label update now specifies an age limit. *Updated to exact verbiage from guidelines for requirements of diagnosing CSID from small bowel biopsy and moved these specific requirements to a standard list format with "AND"s. |
1/1/26 | 10/24/25 |
| myprime.com | Thrombopoietin Receptor Agonists and Tavalisse | UPDATE | *Added option for pediatric patients for persistent immune (idiopathic) thrombocytopenia (ITP) within initial criteria. *Added the following indication for Doptelet to FDA Table: Treatment in pediatric patients 1 year and older with persistent or chronic immune thrombocytopenia who have had an insufficient response to a previous treatment; added Doptelet Sprinkles to formulation FDA Table; limited requests for Doptelet Sprinkle to patients age 1 year to less than 6 years of age. *Limited requests for Doptelet Sprinkle to patients age 1 year to less than 6 years of age. *Added Doptelet Sprinkles to formulation FDA Table. *Added new target agent Wayrilz to FDA Indications table along with corresponding criteria and QL of 60/30. |
1/1/26 | 10/24/25 |
| myprime.com | Topical Antibiotics and Combinations | UPDATE | *Added Cabtreo as a Target Agent in this program. Moved from Retinoids (topical) PA program. *Removal of Veltin (MSC-O). *Step Table: Added Cabtreo. Removed drugs that are not currently Target Agents in this program. Combined Finacea gel line with the foam. *Added "that is NOT expected to occur with the requested agent" on intolerance/hypersensitivity and CI prerequisite requirements due to overlapping active drugs. *Added MSC-Y Cabtreo as a potential prerequisite. |
1/1/26 | 10/24/25 |
| myprime.com | Topical Antifungals itraconazole terbinafine | UPDATE | *Moved Tolsura and terbinafine (and mention of both agents throughout criteria) out of the Sporanox module and into their own modules due to the complexities of the FDA labeled indications and associated requirements. *Jublia: added criteria to assess for another FDA labeled indication or compendia supported indication to support downstream Clinical Operations and specified the allowed compendia sources (AHFS, DrugDex 1 or 2a level of evidence). *Jublia, Sporanox, terbinafine: removed requirement for needing to have an additional diagnosis or complication to the diagnosis of onychomycosis as current guidelines do not support this. *Jublia, Sporanox, terbinafine: added "biopsy" to the lab test options for diagnosing onychomycosis and listed out each lab test in a standard outline fashion with the corresponding "OR"s. *Sporanox: added FDA labeled diagnoses of blastomycosis, histoplasmosis, disseminated non-meningeal histoplasmosis, chronic cavitary pulmonary disease, oropharyngeal and esophageal candidiasis and the corresponding dosage forms they are FDA labeled for. *Sporanox: added diagnosis of aspergillosis for Sporanox capsules with standard verbiage of prereq requirement of amphotericin B from FDA labeling. *Sporanox and Tolsura: added indication of "prophylaxis against invasive aspergillosis" with additional requirements from current IDSA guidelines for the diagnosis and management of aspergillosis for itraconazole. *Sporanox: updated the length of approval for oropharyngeal and esophageal candidiasis from 6 weeks to 8 weeks from clinical trials from the prescribing information. *Tolsura: added diagnoses of blastomycosis, histoplasmosis, disseminated non-meningeal histoplasmosis, chronic cavitary pulmonary disease that follows FDA labeling to be used in both immunocompromised and non-immunocompromised patients. *Tolsura: added diagnosis of aspergillosis with standard verbiage of prereq requirement of amphotericin B from FDA label. *Tolsura: added the standard age criteria as this target is limited to use in adults and moved this so it is only applying to FDA labeled indications. *Tolsura: added standard brand/generic requirement to step Tolsura through generic itraconazole capsule due to cost. |
1/1/26 | 10/24/25 |
| myprime.com | Topical Doxepin | UPDATE | *Mirrored the prereq criteria language for atopic dermatitis for topical corticosteroids and topical calcineurin inhibitors to match other PS programs with this indication. *Added the criteria for topical emollients/good skin care practices to atopic dermatitis that mirrors other PS programs with this indication. *Moved the criteria point for max of 8 days of therapy so it is connected to only the FDA labeled indications with this limitation on duration of therapy. *Removed from concomitant therapy with another topical doxepin "for the requested indication" as intent is to prevent duplicate use. |
1/1/26 | 10/24/25 |
| myprime.com | Topical Lidocaine | UPDATE | *Removed obsolete target: Synera (Lidocaine-Tetracaine 70-70 mg) Patch (GPI 90859902845920). *Termed target: Lidotral (Lidocaine 5% gel) (GPI 90850060104030). *Termed target: Lidocaine 2% gel (GPI 90850060104005). |
1/1/26 | 10/24/25 |
| myprime.com | Topiramate ER | UPDATE | *Moved the age criteria so that it does not apply to "medication history of use of an anti-seizure medication that is not topiramate" to be consistent with how reviews are done between the criteria and SmartEdit and Point of Sale. | 1/1/26 | 10/24/25 |
| myprime.com | Triptans | UPDATE | *Addition of double step for Symbravo per trade strategy. Require a step through rizatriptan + meloxicam combo AND another generic triptan + meloxicam combo. *Prerequisite table updated. |
1/1/26 | 10/24/25 |
| myprime.com | Urea Cycle Disorders | UPDATE | *Standardized renewal clinical benefit check. | 1/1/26 | 10/24/25 |
| myprime.com | Vasomotor Symptoms | UPDATE | *Addition of "serum" and "serum ALP" to hepatic function check per prescribing information/boxed warning. Added total bilirubin less than 2 times upper limit of normal per prescribing information from “total bilirubin is normal”. In addition, updated hepatic function check for renewal per prescribing information calling out explicit discontinuation guidelines. | 1/1/26 | 10/24/25 |
| myprime.com | Voxzogo | UPDATE | *Removed "The requested agent will be used to increase linear growth" requirement per competitor analysis. | 1/1/26 | 10/24/25 |
| myprime.com | Weight Management | UPDATE | *Updated NASH/MASH requirements to have the FIB-4 score be TWO of 4 requirements. *Moved the liver biopsy requirement to be ONE of so that either a liver biopsy is required or TWO or more of FIB-4, Vibration-controlled transient elastography (VCTE), Enhanced liver fibrosis (ELF) score, Magnetic resonance elastography (MRE). *Both modules, updated NASH/MASH requirements to remove stage F1 (due to the new FDA label) and BMI (due to contracting). *Updated diagnosis requirement to match FDA label. |
1/1/26 | 10/24/25 |
| myprime.com | Yorvipath | UPDATE | *Added teriparatide and Tymlos (abaloparatide) to the disallowance/duplicate therapy requirement due to a client request and updated in this same requirement "and" to "or". | 1/1/26 | 10/24/25 |
| myprime.com | Zeposia | UPDATE | *Step Table (Simponi for UC): Removed note requiring T/F of an adalimumab product. Will now allow/accept previous T/F of any of the Step 1 agents. Contracts used to specify only Humira could be used, but that has changed. This update will prevent disadvantaging the other preferred products. Ascent approved/provided guidance on this change. | 1/1/26 | 10/24/25 |
| myprime.com | GLP-1 Agonists | UPDATE | *Added in both modules the MASH diagnosis as ONE of the following: "The patient has a diagnosis of noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH), formerly known as nonalcoholic steatohepatitis (NASH), with moderate to advanced liver fibrosis (consistent with stages F2 to F3 fibrosis)" due to the new FDA indication for semaglutide (Wegovy). | 1/1/26 | 10/24/25 |
| 12.01.085 | Ctexli | NEW | Implementation of NEW guidelines. | 1/1/26 | 9/22/25 |
| 12.01.086 | Qfitlia | NEW | Implementation of NEW guidelines. | 1/1/26 | 9/22/25 |
| 12.01.087 | Zelsuvmi | NEW | Implementation of NEW guidelines. | 1/1/26 | 9/22/25 |