Prior Authorization Updates

Blue Cross Blue Shield of Wyoming (BCBSWY) is committed to providing our Provider community with updates and best practices to improve the processes required to submit prior authorizations for your patients.

We understand that the prior authorization process can be confusing. Here are some important updates to know about:

New Medical Policies: BCBSWY has recently updated posted medical policy updates effective 2/1/25. Click here to view these updates.

Drug prior authorization requests: Recent changes in the process for drug prior authorization requests have occurred due to updates with one of our vendors.

Review the following steps clarify the procedures for submitting a pharmacy prior authorization. Please note that step two is a temporary workaround while we review potential solutions. We hope this helps reduce some of the confusion caused by the recent changes.

Submitting a Pharmacy prior authorization:

1: For Members with Prefixes ZSF, QWY, or ZSK:

Submit the request through covermymeds®.

2: For Members with IDs Starting with ZRW, ZSD, ZWY, or YWY:

Complete the correct pharmacy prior authorization form from MyPrime and save it as a PDF.
Fill out the Availity request with the following key points:
Do not use the covermymeds link. Use “Authorization Request.”
The request type is “Outpatient” Authorization.
If the drug doesn’t have its own HCPCS code, use “J3490 – Unclassified Drugs” for the procedure code.
Complete provider details.
Upload the saved drug-specific form under “Recent attachments.”
Complete the rest of the Availity form.

If you would like additional information, please click on the button below. This is a step-by-step guide for submitting BCBSWY pharmacy prior authorizations through Availilty.

Click Here for the Guide

FEP PRIOR AUTHORIZATIONS

We are aware that FEP in-patient authorization letters are being sent without member information. To view FEP authorization status login to the Availity provider portal and use the Authorization Dashboard to find the status.

A solution has been identified, and work is in progress to correct this technical issue.

IMPORTANT DATES

Upcoming Business Hours & Closures

Tuesday, Dec. 24: Closing at noon
Wednesday, Dec. 25: Closed
Tuesday, Dec. 31: Closing at 3:00 p.m.
Wednesday, Jan. 1: Closed

Preventive Visits Webinar – January 15, 2025

This webinar is geared toward primary care and family practices. BCBSWY will review coding requirements, including proper CPT codes and diagnosis codes to ensure correct billing practices. This, in addition to proper coding for sick visits when combined with annual wellness visits and the reimbursement policy.

Register Now

Provider Directory Validation Reminder

You can find the Provider Directory Validation guide under the Provider Resources section on the right rail of the website.

Providers can use the Directory Validation tool on the Availity Portal to find NPI and tax ID combinations.

No Surprises Act (NSA) requires you confirm this information every 90 days.

Confirm Today!

Coding Update – J3490

Effective 10/1/24 prior authorizations using dump code J3490 can no longer be used if the requested drug is listed on the BCBSWY redirection of care (ROC) list. Prior authorizations using J3490 will be rejected, using the appropriate HCPCS code will correct this issue.

View the current ROC list »

Provider Directory Validation Reminder

You can find the Provider Directory Validation guide under the Provider Resources section on the right rail of the website.

Providers can use the Directory Validation tool on the Availity Portal to find NPI and tax ID combinations.

The No Surprises Act (NSA) requires you confirm this information every 90 days.

Confirm today »

Prior Authorization Tip

Availity Users: Here is how to use the Authorization/Referral Inquiry and the Authorization/Referral Dashboard in Availity:

Inquiry allows users to search for any authorizations that they have submitted/edited individually

Dashboard allows users to search for an authorization submitted by any user assigned to your organization

Updated: The BCBSWY Provider Manual Prior Authorization section was updated to reflect current review timelines. Find the new version here.

We encourage you to forward this newsletter to any associate who may want to subscribe and receive BCBSWY updates. Use the button below.

Reimbursement Reminders – July 2024

Reimbursement Update

Blue Cross Blue Shield of Wyoming is committed to providing you with updates on upcoming policy and reimbursement changes. The following reimbursement policy reminders have been communicated in recent provider updates:

Effective, 9/1/24, BCBSWY is updating our ASC rates and rules. ASC rates can be found in the Availity portal under the BCBSWY resources payer space.
Effective 9/1/2024, infusion pumps (E0779, E0780, and E0781) will be reimbursed as a monthly rental instead of a daily payment. For services after 9/1/2024, if the amount that BCBSWY has paid for the pump exceeds our purchase allowance, we will deny additional claims. Services prior to 9/1/2024 may be considered in this calculation.
Effective 10/1/2024, BCBSWY will implement a 5% reduction in allowed for traditional radiology services, excluding oncology.

Medical policy updates are now available.

To view upcoming policy changes please visit: Medical Policy Updates – Blue Cross Blue Shield of Wyoming (bcbswy.com)

Prevent rejection when submitting medical records through Availity

Reminder, medical records submitted through Availity need to include a claim’s adjustment form or other documentation stating why the medical records are being submitted. If there is no claim adjustment form, the medical records will be rejected and will need to be resubmitted with documentation.

Provider Directory Validation Reminder

You can find the Provider Directory Validation guide under the Provider Resources section on the right rail of the website. Providers can use the Directory Validation tool on the Availity Portal to find NPI and tax ID combinations.

The No Surprises Act (NSA) requires you confirm this information every 90 days.

Confirm Today

Early Closure – Wed. July 24

In celebration of Cheyenne Day, BCBSWY will be closing at noon next Wednesday, July 24th.

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, medical and 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 Member.YourWyoBlue.com to search prior authorization requirements for their benefit plan. Providers can learn more about prior authorization requirements here.

In compliance with Centers for Medicare & Medicaid Services (CMS), a listing of all procedures (excluding prescriptions or medical drugs) requiring prior authorization for members with a Health Insurance Marketplace^ plan can be found here →

^CMS Health Insurance Marketplace list does not apply to group insurance plans. Please verify Prior Authorization requirements with BCBSWY to ensure coverage status.

This page is not valid for FEP members.

This page is only valid for members with BCBSWY membership and not other Blue plans.

The BCBSWY Membership Prefixes are:

QWY YWY ZRW ZSD ZSF ZSH ZSK ZSP ZYW

Medical Policy Updates

Use the Policy Number, Policy Title, or CPT Codes to find and view the full medical policy.

Search Medical Policy Updates

Filters

Policy #

Change Type

Effective Date

Provider Notification Date

Policy #	Policy Title	Change Type	Summary of Changes	Effective Date	Provider Notification Date
04.01.021	Noninvasive Prenatal Screening for Fetal Aneuploidies, Microdeletions, Single-Gene Disorders, and Twin Zygosity Using Cell-Free Fetal DNA	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed. Code 0633U added.	12/14/26	10/12/26
07.01.122	Electromagnetic Navigational Bronchoscopy	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed. Code 0633U added.	12/14/26	10/12/26
07.01.121	Saturation Biopsy for Diagnosis, Staging, and Management of Prostate Cancer	NEW	Implementation of NEW guidelines	12/7/26	10/5/26
08.01.043	Radioembolization for Primary and Metastatic Tumors of the Liver	NEW	Implementation of NEW guidelines	12/7/26	10/5/26
08.01.053	Cellular Immunotherapy for Prostate Cancer	NEW	Implementation of NEW guidelines	12/7/26	10/5/26
02.01.073	Actigraphy	DELETE	Archiving the criteria	12/7/26	10/5/26
07.01.128	Bronchial Valves	DELETE	Archiving the criteria	12/7/26	10/5/26
07.01.145	Laminectomy	DELETE	Archiving the criteria	12/7/26	10/5/26
02.04.029	Analysis of human DNA in Stool Samples as a Technique for Colorectal Cancer Screening	DELETE	Archiving the criteria	12/7/26	10/5/26
02.04.010	Identification of Microorganisms Using Nucleic Acid Probes	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	12/7/26	10/5/26
02.04.104	Genetic Testing for α-Thalassemia	UPDATE	Information related to preconception (carrier) testing for α-thalassemia was removed from the policy and policy statements were updated to reflect this removal.	12/7/26	10/5/26
02.04.119	Multibiomarker Disease Activity Blood Test for Rheumatoid Arthritis	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	12/7/26	10/5/26
02.04.140	Proteogenomic Testing for Patients With Cancer	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	12/7/26	10/5/26
02.04.151	Genetic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Advanced Cancer	UPDATE	Table 1 updated with new entries. Title changed to exclude the word biomarkers. Medically necessary policy statement added for KMT2A gene rearrangement variant testing for individuals with relapsed or refractory acute leukemia to select individuals for treatment with FDA-approved therapies. Policy statement regarding KIT D816V was revised for clarity but intent was not changed. Other policy statements unchanged.	12/7/26	10/5/26
02.04.158	Multicancer Early Detection Testing	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	12/7/26	10/5/26
02.04.038	Cytochrome P450 Genotype-Guided Treatment Strategy	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	12/7/26	10/5/26
02.04.048	Genotype-Guided Warfarin Dosing	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	12/7/26	10/5/26
02.01.049	Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) for Benign Prostatic Hyperplasia	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	12/7/26	10/5/26
07.01.131	Transcatheter Pulmonary Valve Implantation	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	12/7/26	10/5/26
07.01.018	Automated Percutaneous and Percutaneous Endoscopic Discectomy	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	12/7/26	10/5/26
07.01.071	Lung Volume Reduction Surgery for Severe Emphysema	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	12/7/26	10/5/26
08.01.067	Medical Management of Obstructive Sleep Apnea Syndrome	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	12/7/26	10/5/26
08.01.011	Transcatheter Arterial Chemoembolization to Treat Primary or Metastatic Liver Malignancies	DELETE	Archiving the criteria	11/30/26	9/28/26
07.01.091	Radiofrequency Ablation of Primary or Metastatic Liver Tumors	DELETE	Archiving the criteria	11/30/26	9/28/26
02.03.007	Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies	DELETE	Archiving the criteria	11/30/26	9/28/26
02.01.082	Bioimpedance Devices for Detection and Management of Lymphedema	DELETE	Archiving the criteria	11/30/26	9/28/26
08.01.062	Electronic Brachytherapy for Nonmelanoma Skin Cancer	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/30/26	9/28/26
08.01.006	Oncologic Applications of Photodynamic Therapy, Including Barrett Esophagus	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/30/26	9/28/26
07.01.092	Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone	UPDATE	Cryoablation in early-stage breast cancer moved to individual PICO. Policy statements edited for clarity and to include single statement for breast indications. Intent otherwise unchanged.	11/30/26	9/28/26
06.01.055	Selected Positron Emission Tomography Technologies for Evaluation of Alzheimer Disease	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/30/26	9/28/26
06.01.055	Selected Positron Emission Tomography Technologies for Evaluation of Alzheimer Disease	UPDATE	Clinical evidence to support the policy position was reviewed and references added.There is no change to the policy position statement listed.	11/30/26	9/28/26
02.04.041	Genetic Testing for Diagnosis and Management of Mental Health Conditions	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/30/26	9/28/26
02.04.110	Genetic Testing for Diagnosis and Management of Mental Health Conditions	UPDATE	Investigational policy statement test examples updated to align with Regulatory Status section; intent unchanged.	11/30/26	9/28/26
02.04.101	Genetic Testing for Li-Fraumeni Syndrome	UPDATE	Policy updated with literature review through May 19, 2026; reference added. Minor editorial refinements to policy statements; intent unchanged.	11/30/26	9/28/26
01.01.018	Compression Pumps for Treatment of Lymphedema and Venous Ulcers	UPDATE	Policy updated with literature review through May 22, 2026; references added. Policy statements edited to consistently distinguish between programmable and nonprogrammable devices using italics. Policy statement intent unchanged.	11/30/26	9/28/26
02.01.100	Dry Needling of Trigger Points for Myofascial Pain	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
02.01.054	Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
02.01.054	Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
02.01.098	Orthopedic Applications of Platelet-Rich Plasma	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
02.04.054	Molecular Genomic Profiling for Cancers of Unknown Primary	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
02.04.082	Genetic Testing for Inherited Thrombophilia	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
02.04.087	Genetic Testing for Hereditary Hearing Loss	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
06.01.025	Minimally Invasive Approaches to Vertebral Fractures and Osteolytic Lesions of the Spine	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
07.01.007	Electrical Bone Growth Stimulation of the Appendicular Skeleton	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
07.01.100	Bone Morphogenetic Protein	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
07.01.108	Artificial Intervertebral Disc: Cervical Spine	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
07.01.120	Facet Arthroplasty	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
07.01.125	Occipital Nerve Stimulation	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
07.01.126	Image-Guided Minimally Invasive Decompression for Spinal Stenosis	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
07.01.143	Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
07.01.025	Spinal Cord and Dorsal Root Ganglion Stimulation	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
07.01.048	Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
07.01.063	Deep Brain Stimulation	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
07.01.069	Sacral Nerve Neuromodulation/Stimulation	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
07.01.078	Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
01.01.005	Ultrasound Accelerated Fracture Healing Device	DELETE	Archiving the criteria	11/9/26	9/8/26
07.01.104	Subtalar Arthroereisis	DELETE	Archiving the criteria	11/9/26	9/8/26
07.01.107	Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)	DELETE	Archiving the criteria	11/9/26	9/8/26
07.01.118	Surgical Treatment of Femoroacetabular Impingement	DELETE	Archiving the criteria	11/9/26	9/8/26
07.01.130	Axial Lumbosacral Interbody Fusion	DELETE	Archiving the criteria	11/9/26	9/8/26
07.01.015	Meniscal Allografts and Other Meniscal Implants	DELETE	Archiving the criteria	11/9/26	9/8/26
07.01.080	Hip Resurfacing	DELETE	Archiving the criteria	11/9/26	9/8/26
07.01.093	Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty)	DELETE	Archiving the criteria	11/9/26	9/8/26
08.01.058	Cranial Electrotherapy Stimulation and Auricular Electrostimulation	DELETE	Archiving the criteria	11/9/26	9/8/26
08.03.009	Vertebral Axial Decompression	DELETE	Archiving the criteria	11/9/26	9/8/26
12.01.005	Calcium Sensing Receptor Agonists - Parsabiv	DELETE	Archiving the criteria	11/9/26	9/8/26
01.01.024	Interferential Current Stimulation	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
02.01.050	Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
02.01.056	Low Level Laser Therapy	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
02.01.096	Autonomic Nervous System Testing	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
02.02.009	Closure Devices for Patent Foramen Ovale and Atrial Septal Defects.	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
02.02.010	Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
02.02.024	Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
02.02.032	Leadless Cardiac Pacemakers	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
02.02.033	Phrenic Nerve Stimulation for Central Sleep Apnea	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
02.04.014	Evaluation of Biomarkers for Alzheimer Disease	UPDATE	Policy statements changed to include the specific CSF biomarker tests. New investigational policy statements were added for plasma-based tests. Title changed to "Evaluation of Cerebrospinal Fluid, Urine, and Plasma Tests for Alzheimer Disease".	11/9/26	9/8/26
02.04.142	Molecular Testing in the Management of Pulmonary Nodules	UPDATE	The policy statement for the Percepta Genomic Sequencing Classifier was removed as the product is no longer marketed. Furthermore, the REVEAL Lung Nodule Characterization by MagArray was removed from the policy statements as the company is no longer in business. Evidence review for the Percepta Genomic Sequencing Classifier was removed.	11/9/26	9/8/26
02.04.146	Gene Expression Profiling for Cutaneous Melanoma	UPDATE	New indication and policy statement added for the CP-GEP Merlin assay. Policy statements unchanged.	11/9/26	9/8/26
02.04.152	Maternal Serum Biomarkers for Prediction of Adverse Obstetric Outcomes	UPDATE	Policy statements updated to include testing of maternal serum cell-free RNA as investigational. Biomarker nomenclature removed from policy statements. Title changed to "Maternal Serum Testing for Prediction of Adverse Obstetric Outcomes."	11/9/26	9/8/26
02.04.153	Tumor-Informed Circulating Tumor DNA Testing for Cancer Management	UPDATE	Added a new PICO for Merkel Cell Carcinoma (MCC). Policy statements unchanged.	11/9/26	9/8/26
02.04.080	Genetic Testing for Hereditary Hemochromatosis	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
06.01.003	Computed Tomography to Detect Coronary Artery Calcification	UPDATE	Updated policy statements regarding coronary artery scoring, artificial intelligence-based automated detection and use of computed tomography to detect coronary artery calcification.	11/9/26	9/8/26
07.01.113	Bioengineered Skin and Soft Tissue Substitutes	UPDATE	Kerecis Omega3 moved from investigational to medically necessary for the treatment of diabetic lower-extremity ulcers. All other policy statements unchanged. Indication 5 intervention wording changed from "acellular dermal matrix products" to "bioengineered skin substitutes" for clarity.	11/9/26	9/8/26
07.01.124	Treatment of Varicose Veins/Venous Insufficiency	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
07.01.147	Minimally Invasive Ablation Procedures for Morton and Other Peripheral Neuromas	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
07.01.149	Amniotic Membrane and Amniotic Fluid	UPDATE	Summary of evidence paragraph for venous leg ulcers corrected from "sufficient" to "insufficient" to align with the evidence review overview table and investigational policy statement. Ophthalmic medically necessary statements clarified to specify applicability to any human amniotic membrane product commercially available for ophthalmic use. Two investigational comprehensive statements consolidated into a single statement. Standalone ophthalmic investigational statement removed as redundant with consolidated comprehensive statement. Intent unchanged. All other policy statements unchanged.	11/9/26	9/8/26
07.01.154	Ablation of Peripheral Nerves to Treat Pain	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
07.01.168	Cryoablation, Radiofrequency Ablation, and Laser Ablation for Treatment of Chronic Rhinitis	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
07.01.044	Implantable Cardioverter Defibrillators	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed. Codes 0571T and 0572T added.	11/9/26	9/8/26
07.01.085	Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
08.01.010	Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/9/26	9/8/26
08.01.025	Hematopoietic Cell Transplantation for Autoimmune Diseases	UPDATE	Policy statement for multiple sclerosis was changed from investigational to medically necessary with criteria, based on responses to a structured request for clinical input. All other policy statements unchanged.	11/9/26	9/8/26
02.01.039	Quantitative Sensory Testing	DELETE	Archiving the criteria	11/9/26	9/8/26
02.01.083	Interventions for Progressive Scoliosis	DELETE	Archiving the criteria	11/9/26	9/8/26
07.01.166	Allograft Injection for Degenerative Disc Disease	DELETE	Archiving the criteria	11/9/26	9/8/26
01.01.029	Tumor Treating Fields Therapy	UPDATE	Regulatory Status section updated to include new FDA indication for non-small sell lung cancer. Non-small cell lung cancer added to list of conditions for which the therapy is considered investigational.	11/9/26	9/8/26
02.01.106	Percutaneous Electrical Nerve Field Stimulation for Irritable Bowel Syndrome	NEW	Implementation of NEW guidelines	11/9/26	9/8/26
03.03.006	Immersive Virtual Reality Therapy for Chronic Lower Back Pain	NEW	Implementation of NEW guidelines	11/9/26	9/8/26
06.01.038	Percutaneous Balloon Kyphoplasty, Radiofrequency Kyphoplasty, and Mechanical Vertebral Augmentation	DELETE	Archiving the criteria	11/9/26	9/8/26
04.01.021	Noninvasive Prenatal Screening for Fetal Aneuploidies, Microdeletions, Single-Gene Disorders, and Twin Zygosity Using Cell-Free Fetal DNA	NEW	Implementation of NEW guidelines	11/9/26	9/8/26
09.03.023	Intravitreal and Punctum Corticosteroid Implants	DELETE	Archiving the criteria.	11/2/26	8/31/26
09.03.001	Keratoprosthesis	DELETE	Archiving the criteria.	11/2/26	8/31/26
01.01.030	Automated Insulin Delivery Systems	DELETE	Archiving the criteria.	11/2/26	8/31/26
01.01.011	Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/2/26	8/31/26
01.01.026	Cooling Devices Used in the Outpatient Setting	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/2/26	8/31/26
01.01.027	Electrical and Electromagnetic Stimulation for the Treatment of Arthritis	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/2/26	8/31/26
01.01.028	Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/2/26	8/31/26
01.03.004	Powered Exoskeleton for Ambulation in Patients With Lower-Limb Disabilities	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/2/26	8/31/26
01.03.005	Patient-Controlled End Range of Motion Stretching Devices	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/2/26	8/31/26
01.04.004	Myoelectric Prosthetic and Orthotic Components for the Upper Limb	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/2/26	8/31/26
01.04.005	Microprocessor-Controlled Prostheses for the Lower Limb	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/2/26	8/31/26
02.02.028	Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/2/26	8/31/26
02.04.103	Genetic Testing for Macular Degeneration	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/2/26	8/31/26
02.04.160	Circulating Tumor-Tissue-Modified Viral DNA Testing for Cancer Management	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/2/26	8/31/26
02.04.044	Germline Genetic Testing for Familial Cutaneous Malignant Melanoma (CDKN2A, CDK4)	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/2/26	8/31/26
02.04.068	Laboratory and Genetic Testing for Use of 5-Fluorouracil in Patients With Cancer	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/2/26	8/31/26
02.04.086	Genetic Testing for Duchenne and Becker Muscular Dystrophy	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/2/26	8/31/26
07.01.014	Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures)	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/2/26	8/31/26
07.01.168	Cryoablation, Radiofrequency Ablation, and Laser Ablation for Treatment of Chronic Rhinitis	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/2/26	8/31/26
08.03.001	Functional Neuromuscular Electrical Stimulation	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/2/26	8/31/26
08.03.013	Sensory Integration Therapy and Auditory Integration Therapy	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/2/26	8/31/26
09.03.008	Photodynamic Therapy for Choroidal Neovascularization	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/2/26	8/31/26
05.01.019	Injectable Clostridial Collagenase for Fibroproliferative Disorders	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	11/2/26	8/31/26
12.01.018	Infusible Biologic Immunomodulator - Actemra®, Avsola®, Avtozma, Cimzia® , Cosentyx®, Entyvio®, Ilumya®, Imuldosa, Inflectra®, Omvoh®, Orencia®, Otulfi™, Pyzchiva®, Remicade®, Infliximab, Renflexis®, Selarsdi™ Simponi ARIA®, Skyrizi®, Stelara®, Steqeyma®, Taltz®, Tofidence™, Tremfya®, Tyenne®, Wezlana™, Yesintek™	UPDATE	Moved Avtozma to a preferred step position; will now share the same step position as Tyenne for all indications (pJIA, RA, sJIA, GCA, SSc-ILD) Updated Avtozma to be eligible for CoT by removing it as an exception in the CoT table	11/2/26	8/26/26
07.01.058	Intraoperative Neurophysiologic Monitoring	DELETE	Archiving the criteria.	10/26/26	8/24/26
07.01.021	Reduction Mammaplasty for Breast-Related Symptoms	NEW	Implementation of NEW guidelines.	10/26/26	8/24/26
06.01.003	Computed Tomography to Detect Coronary Artery Calcification	UPDATE	Clinical evidence to support the policy position was reviewed. Policy statement updated to: Coronary artery calcium scoring may be considered medically necessary as an adjunct to standard cardiovascular risk assessment in asymptomatic adults without known coronary artery disease or clinical atherosclerotic cardiovascular disease in individuals at least 40 years of age and borderline to intermediate 10-year atherosclerotic cardiovascular disease risk and who are currently not on lipid-lowering therapy (see Policy Guidelines). Artificial intelligence-based automated detection, quantification, or scoring of coronary artery calcium on chest computed tomography, whether performed on dedicated ECG-gated calcium-scoring CT in asymptomatic patients or on non-contrast, non-ECG-gated chest CT performed for other clinical indications as an adjunct to standard cardiovascular risk assessment, is considered investigational. The use of computed tomography to detect coronary artery calcification is considered investigational for all other indications.	10/26/26	8/24/26
05.01.042	Gene Therapies for Thalassemia (Casgevy and Zynteglo)	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	10/19/26	8/17/26
01.01.010	Continuous Passive Motion in the Home Setting	UPDATE	Updated policy information under policy position.	10/16/26	8/17/26
12.01.019	Injectable Asthma Agents - Cinqair, Fasenra, Nucala	UPDATE	Updated policy information, including updated policy position information. Cinqair and Nucala moved to separate policies.	10/9/26	8/10/26
12.01.101	Nucala	NEW	Implementation of NEW guidelines. This was previously listed under policy 12.01.019.	10/9/26	8/10/26
12.01.100	Cinqair	NEW	Implementation of NEW guidelines. This was previously listed under policy 12.01.019.	10/9/26	8/10/26
07.01.073	Gastric Electrical Stimulation	DELETE	Archiving the criteria.	10/5/26	8/3/26
07.01.085	Intraoperative Neurophysiologic Monitoring	DELETE	Archiving the criteria.	10/5/26	8/3/26
05.01.028	Treatment for Spinal Muscular Atrophy (Zolgensma)	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	9/28/26	7/27/26
08.01.066	Chimeric Antigen Receptor Therapy for Multiple Myeloma (Abecma, Carvykti)	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	9/28/26	7/27/26
15.01.007	Kisunla	NEW	Implementation of NEW guidelines.	9/28/26	7/27/26
08.01.061	Focal Treatments for Prostate Cancer	UPDATE	Clinical evidence to support the policy position was reviewed. PICO removed for individuals with primary localized prostate cancer who are treated with focal therapy using irreversible electroporation (the PICO is included in policy 6.01.68 - Irreversible Electroporation of Tumors Located in the Liver, Pancreas, Kidney, Lung or Prostate). Policy statements unchanged.	9/21/26	7/20/26
08.01.002	Chelation Therapy for Off-Label Uses	UPDATE	Clinical evidence to support the policy position was reviewed and references added. Policy statement changed to include Parkinson disease among the listed investigational indications based on the growing dedicated body of data; intent unchanged. Added dx codes: G20.A1, G20.A2, G20.B1, G20.B2, G20.C, G21.4, G21.8, G21.9.	9/21/26	7/20/26
07.01.087	Artificial Intervertebral Disc: Lumbar Spine	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	9/21/26	7/20/26
07.01.168	Cryoablation, Radiofrequency Ablation, and Laser Ablation for Treatment of Chronic Rhinitis	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	9/21/26	7/20/26
07.01.158	Balloon Dilation of the Eustachian Tube	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	9/21/26	7/20/26
07.01.155	Functional Endoscopic Sinus Surgery for Chronic Rhinosinusitis	UPDATE	Clinical evidence to support the policy position was reviewed and references added. Policy statements changed as indicated: Balloon dilation of the eustachian tube (BDET) with a device cleared by the U.S. Food and Drug Administration (FDA) for treatment of chronic obstructive eustachian tube dysfunction (ETD) may be considered medically necessary when used according to FDA labeling and under the following conditions: Individuals with symptoms of obstructive ETD (aural fullness, aural pressure, otalgia, and/or hearing loss) for 3 months or longer in 1 or both ears that significantly affects quality of life or functional health status; (For pediatric use (8-17 years of age) of balloon dilation of Eustachian tube see Policy Guidelines.)	9/21/26	7/20/26
07.01.134	Steroid-Eluting Sinus Stents and Implants	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	9/21/26	7/20/26
07.01.105	Balloon Ostial Dilation for Treatment of Chronic and Recurrent Acute Rhinosinusitis	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	9/21/26	7/20/26
07.01.103	Surgical Ventricular Restoration	UPDATE	Clinical evidence to support the policy position was reviewed and references added. Policy statements updated to include children as young as 7 months based on FDA approval of MED-EL in this population.	9/21/26	7/20/26
07.01.005	Cochlear Implant	UPDATE	Clinical evidence to support the policy position was reviewed. There is no change to the policy position statement listed.	9/21/26	7/20/26
07.01.003	Implantable Bone-Conduction and Bone-Anchored Hearing Aids	UPDATE	Clinical evidence to support the policy position was reviewed. There is no change to the policy position statement listed.	9/21/26	7/20/26
08.01.063	Chimeric Antigen Receptor Therapy for Leukemia and Lymphoma (Breyanzi, Carvykti, Kymriah, Yescarta)	UPDATE	Clinical evidence to support the policy position was reviewed. There is no change to the policy position statement listed.	9/21/26	7/20/26
05.01.047	Gene Therapies for Treatment of Wounds in Dystrophic Epidermolysis Bullosa (Vyjuvek)	UPDATE	Clinical evidence to support the policy position was reviewed and references added. Updated policy position for beremagene geperpavec-svdt and broadened clinical criteria.	9/21/26	7/20/26
05.01.030	Treatment of Hereditary Transthyretin-Mediated Amyloidosis in Adult Patients – Onpattro, Amvuttra	UPDATE	Added Redirection of Care information to policy.	9/14/26	7/13/26
07.01.055	Prostate Artery Embolization	NEW	Implementation of NEW guidelines.	9/14/26	7/13/26
07.01.097	Intracoronary Drug Delivery Balloon Procedures	NEW	Implementation of NEW guidelines.	9/14/26	7/13/26
02.01.004	Hyperbaric Oxygen Therapy	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	9/14/26	7/13/26
02.02.008	Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry	UPDATE	Clinical evidence to support the policy position was reviewed and references added. Policy statement for mobile cardiac outpatient telemetry for individuals with signs and/or symptoms suggestive of arrhythmia changed to medically necessary with criteria based on responses to a structured request for clinical input. All other policy statements unchanged.	9/14/26	7/13/26
02.04.109	Genetic Testing for Epilepsy	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	9/14/26	7/13/26
02.04.111	Gene Expression Profiling, Protein Biomarkers, and Multimodal Artificial Intelligence for Prostate Cancer Management	UPDATE	Clinical evidence to support the policy position was reviewed and references added. Added NCCN definitions for Decipher Prostate Genomic Classifier test to the guidelines section. Policy statements unchanged.	9/14/26	7/13/26
02.04.114	Genetic Testing for Idiopathic Dilated Cardiomyopathy	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	9/14/26	7/13/26
02.04.129	Genetic Testing for Marfan Syndrome, Thoracic Aortic Aneurysms and Dissections, and Related Disorders	UPDATE	Clinical evidence to support the policy position was reviewed. There is no change to the policy position statement listed.	9/14/26	7/13/26
02.04.014	Evaluation of Biomarkers for Alzheimer Disease	UPDATE	Clinical evidence to support the policy position was reviewed and references added. Policy statements changed to include the specific CSF biomarker tests. New investigational policy statements were added for plasma-based tests.	9/14/26	7/13/26
02.04.148	Germline Genetic Testing for Pancreatic Cancer Susceptibility Genes (ATM, BRCA1, BRCA2, CDKN2A, EPCAM, MLH1, MSH2, MSH6, PALB2, PMS2, STK11, and TP53)	UPDATE	Clinical evidence to support the policy position was reviewed. There is no change to the policy position statement listed.	9/14/26	7/13/26
02.04.036	Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer	UPDATE	Clinical evidence to support the policy position was reviewed and references added. New PICOs and INV position statement added for neoadjuvant systemic therapy decision-making in early stage breast cancer. Policy Guidelines updated to include new guidance about omitting SLNB in certain patients.	9/14/26	7/13/26
02.04.088	Genetic Testing for PTEN Hamartoma Tumor Syndrome	UPDATE	Clinical evidence to support the policy position was reviewed. There is no change to the policy position statement listed.	9/14/26	7/13/26
02.04.099	Genetic Testing for Hereditary Pancreatitis	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	9/14/26	7/13/26
04.01.019	Laparoscopic, Percutaneous, and Transcervical Techniques for Uterine Fibroid Myolysis	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	9/14/26	7/13/26
07.01.072	Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, Biacuplasty and Intraosseous Basivertebral Nerve Ablation	UPDATE	Clinical evidence to support the policy position was reviewed. Investigational policy statement for Basiverteral Nerve Ablation removed (see policy 15.01.004 criteria).	9/7/26	7/6/26
08.01.062	Electronic Brachytherapy for Nonmelanoma Skin Cancer	NEW	Implementation of NEW guidelines.	9/7/26	7/6/26
15.01.004	Basivertebral Nerve Ablation	UPDATE	There is no change to the policy position statement listed.	9/7/26	7/6/26
15.01.003	Drug Testing in Pain Management and Substance Use Disorder Treatments	UPDATE	There is no change to the policy position statement listed.	9/7/26	7/6/26
05.01.023	Testosterone Replacement Therapies	DELETE	Archiving the criteria.	9/4/26	7/6/26
12.01.099	Atypical Antipsychotics - Extended Maintenance Agents	NEW	Implementation of NEW policy guidelines. Effective 10/1/26, this information will be available at MyPrime.com.	10/1/26	6/29/26
12.01.098	Voyxact	NEW	Implementation of NEW policy guidelines. Effective 10/1/26, this information will be available at MyPrime.com.	10/1/26	6/29/26
02.01.016	Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non-Orthopedic Conditions	NEW	Implementation of NEW guidelines.	8/10/26	6/15/26
02.01.057	Electrostimulation and Electromagnetic Therapy for Treating Wounds	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	8/10/26	6/15/26
02.01.068	Laboratory Tests Post Transplant and for Heart Failure	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	8/10/26	6/15/26
02.04.102	Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed. Minor revisions to PICO and Policy guidelines.	8/10/26	6/15/26
02.04.124	Genetic Testing for FLT3, NPM1, and CEBPA Variants in Cytogenetically Normal Acute Myeloid Leukemia	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	8/10/26	6/15/26
02.04.131	Pharmacogenetic Testing for Pain Management	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	8/10/26	6/15/26
02.04.137	Genetic Testing for Neurofibromatosis	UPDATE	Clinical evidence to support the policy position was reviewed. There is no change to the policy position statement listed.	8/10/26	6/15/26
02.04.043	Genetic Testing for Cardiac Ion Channelopathies	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	8/10/26	6/15/26
02.04.079	Genetic Testing for Alpha-1 Antitrypsin Deficiency	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	8/10/26	6/15/26
02.04.083	Genetic Testing for FMR1 Variants (Including Fragile X Syndrome)	UPDATE	Clinical evidence to support the policy position was reviewed. There is no change to the policy position statement listed.	8/10/26	6/15/26
02.04.089	Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	8/10/26	6/15/26
07.01.047	Bariatric Surgery	UPDATE	Clinical evidence to support the policy position was reviewed and references added. Policy guidelines updated to reflect current clinical practice guidelines. Policy statements revised to move SADI-S to medically necessary from investigation; minor editorial refinements. Added code C9784.	8/10/26	6/15/26
08.01.015	Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma	UPDATE	Clinical evidence to support the policy position was reviewed and references added. Policy statements updated for clarity and concordance with current guidelines.	8/10/26	6/15/26
08.01.017	Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	8/10/26	6/15/26
08.01.020	Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas	UPDATE	Clinical evidence to support the policy position was reviewed and references added. Minor editorial refinements made to policy statements; intent unchanged.	8/10/26	6/15/26
08.01.021	Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	8/10/26	6/15/26
08.01.023	Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer	UPDATE	Clinical evidence to support the policy position was reviewed. There is no change to the policy position statement listed.	8/10/26	6/15/26
08.01.024	Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	8/10/26	6/15/26
08.01.025	Hematopoietic Cell Transplantation for Autoimmune Diseases	UPDATE	Clinical evidence to support the policy position was reviewed and references added. Policy statement for multiple sclerosis was changed from investigational to medically necessary with criteria, based on responses to a structured request for clinical input. All other policy statements unchanged.	8/10/26	6/15/26
08.01.026	Hematopoietic Cell Transplantation for Acute Myeloid Leukemia	UPDATE	Clinical evidence to support the policy position was reviewed. There is no change to the policy position statement listed.	8/10/26	6/15/26
08.01.028	Hematopoietic Cell Transplantation for Central Nervous System Embryonal Tumors and Ependymoma	UPDATE	Clinical evidence to support the policy position was reviewed. Policy statements edited to remove reference to archived policy.	8/10/26	6/15/26
08.01.029	Hematopoietic Cell Transplantation for Hodgkin Lymphoma	UPDATE	Clinical evidence to support the policy position was reviewed. There is no change to the policy position statement listed.	8/10/26	6/15/26
08.01.030	Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia	UPDATE	Clinical evidence to support the policy position was reviewed. There is no change to the policy position statement listed.	8/10/26	6/15/26
08.01.032	Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	8/10/26	6/15/26
08.01.034	Hematopoietic Cell Transplantation for Solid Tumors of Childhood	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	8/10/26	6/15/26
08.01.035	Hematopoietic Cell Transplantation in the Treatment of Germ Cell Tumors	UPDATE	Clinical evidence to support the policy position was reviewed. There is no change to the policy position statement listed.	8/10/26	6/15/26
08.01.042	Hematopoietic Cell Transplantation for Primary Amyloidosis	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	8/10/26	6/15/26
08.01.052	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 reviewed and references added. There is no change to the policy position statement listed.	8/10/26	6/15/26
08.01.055	Stem Cell Therapy for Peripheral Arterial Disease	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	8/10/26	6/15/26
12.01.097	Zycubo	NEW	Implementation of NEW guidelines. Effective 9/1/2026, this policy will be available on MyPrime.com.	9/1/26	6/8/26
12.01.096	Cardamyst (etripamil)	NEW	Implementation of NEW guidelines. Effective 8/10/2026, this policy will be available on MyPrime.com.	8/10/26	6/8/26
12.01.095	Aqvesme	NEW	Implementation of NEW guidelines. Effective 8/10/2026, this policy will be available on MyPrime.com.	8/10/26	6/8/26
09.03.021	Aqueous Shunts and Stents for Glaucoma	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	7/27/26	6/1/26
07.03.011	Total Artificial Hearts and Implantable Ventricular Assist Devices	UPDATE	Clinical evidence to support the policy position was reviewed and references added. Studies focused on ventricular assist devices (HeartWare, Novacor) that have been discontinued and lack any available upgrades has been excluded from the Rationale section. There is no change to the policy position statement listed.	7/27/26	6/1/26
07.01.020	Vagus Nerve Stimulation	UPDATE	Clinical evidence to support the policy position was reviewed and references added. Policy statements updated to include rheumatoid arthritis: Vagus nerve stimulation is considered investigational as a treatment of other conditions, including but not limited to depression, heart failure, upper-limb impairment due to stroke, essential tremor, headaches, rheumatoid arthritis, fibromyalgia, tinnitus, and traumatic brain injury. Added code C1607.	7/27/26	6/1/26
07.01.167	Adjunctive Techniques for Screening, Surveillance, and Risk Classification of Barrett Esophagus and Esophageal Dysplasia	UPDATE	Clinical evidence to support the policy position was reviewed and references added. BarreGen was discontinued as of May 30, 2025, so its PICO and policy statement were removed. A new PICO was added for Esopredict and is considered investigational for assessing the risk of progression to high-grade dysplasia or esophageal adenocarcinoma in individuals with Barrett esophagus. All other policy statements are unchanged. Code 0398U added.	7/27/26	6/1/26
07.01.112	Transanal Endoscopic Microsurgery	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	7/27/26	6/1/26
02.04.125	Proteomic Testing for Targeted Therapy in Non-Small-Cell Lung Cancer	UPDATE	Clinical evidence to support the policy position was reviewed. There is no change to the policy position statement listed.	7/27/26	6/1/26
05.01.013	Pharmacologic Treatments for Metabolic Dysfunction-Associated Steatohepatitis	DELETE	Archiving the criteria.	8/1/26	6/1/26
12.01.006	Colony Stimulating Factors - Fulphila, Fylnetra, Granix, Leukine, Neulasta, Neupogen, Nivestym, Nypozi, Nyvepria, Releuko, Rolvedon, Stimufend, Udenyca, Zarxio, Ziextenzo	UPDATE	Updated policy information, including updated policy position information.	8/1/26	5/26/26
05.01.047	Gene Therapies for Treatment of Wounds in Dystrophic Epidermolysis Bullosa (Vyjuvek)	UPDATE	Removed 6-month authorization limit.	7/27/26	5/26/26
12.01.068	Soliris (eculizumab) and Ultomiris (ravulizumab-cwvz) Medical Drug Criteria	DELETE	Archiving the criteria.	7/27/26	5/26/26
12.01.047	Soliris	UPDATE	Updated title to "Soliris and Ultomiris" and added language surrounding Redirection of Care.	7/27/26	5/26/26
06.01.046	Dynamic Spinal Visualization and Vertebral Motion Analysis	UPDATE	Clinical evidence to support the policy position was reviewed. There is no change to the policy position statement listed.	7/20/26	5/18/26
06.01.023	Diagnosis and Treatment of Sacroiliac Joint Pain	UPDATE	Clinical evidence to support the policy position was reviewed. There is no change to the policy position statement listed.	7/20/26	5/18/26
06.01.026	Oncologic Applications of Positron Emission Tomography Scanning (Genitourinary)	UPDATE	Clinical evidence to support the policy position was reviewed and references added. Editorial revision throughout policy related to use of guidelines. Intent of policy statements unchanged.	7/20/26	5/18/26
05.40.030	Evkeeza	NEW	Implementation of NEW guidelines.	7/13/26	5/11/26
12.01.094	Alpha-1-Proteinase Inhibitors - Aralast NP, Glassia, Prolastin-C, Zemaira	NEW	Implementation of NEW guidelines.	7/13/26	5/11/26
05.01.009	Advanced Therapies for Pharmacologic Treatment of Pulmonary Hypertension	UPDATE	Clinical evidence to support the policy position was reviewed and references added.There is no change to the policy position statement listed.	7/6/26	5/4/26
05.01.016	Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders	UPDATE	Clinical evidence to support the policy position was reviewed. There is no change to the policy position statement listed.	7/6/26	5/4/26
05.01.044	Treatment of Congenital Athymia	UPDATE	Clinical evidence to support the policy position was reviewed. There is no change to the policy position statement listed.	7/6/26	5/4/26
11.01.127	Wheelchair & Accessories	DELETE	Archiving the criteria.	7/6/26	5/4/26
15.01.006	Wheelchairs and Options/Accessories	NEW	Implementation of NEW guidelines.	7/6/26	5/4/26
myprime.com	Acute Migraine Agents	UPDATE	Added double step to Brekiya and Trudhesa as part of strategy to have patients step through a generic dihydroergotamine injection AND triptan. Included option for provider to provide support as to why patient cannot use injectable as bypass for instances like needle phobia, arthritis, disabilities. Prerequisite table updated to reflect step addition. Updated criteria from "acute migraine treatment" to "the acute treatment of migraines" to aligned with the language used in CGRP policy. Updated clinical benefit check in renewal for indications other than treatment of acute migraines to align with the language used in CGRP policy. Addition of medication overuse headache (MOH) check to QL.	7/1/26	5/4/26
myprime.com	Afrezza	UPDATE	QVT to MDD set up for all QL target agents Addition of Smart Edit.	7/1/26	5/4/26
myprime.com	ATTR Amlyoidosis	UPDATE	*Removed "for the requested indication" and listed all target agents under the "agents not to be used in combination" section of the combination therapy criteria to further disallow concomitant use.	7/1/26	5/4/26
myprime.com	Biologic Immun OP2	UPDATE	Updated examples of what can be accepted for severe psoriatic arthritis to better align with guidelines. Impacts PS, PsA, and JPsA requirements. Psoriasis: Updated phototherapy prerequisite to list PUVA and UVB as possible examples. Hidradenitis Suppurativa: Updated step requirements to only include systemic antibiotic therapies based on new European S2k guideline. Ustekinumab 90 mg: Updated requirements to allow a pathway for patients with psoriasis who weigh 100 kg or less to use the 90 mg strength if they previously had an inadequate response with 45 mg Q12W dosing after 3 months of maintenance therapy; medical records required. (see Discussion Issues During Review below for additional information) Step Table: Updated note regarding intent for trials of multiple dosage forms of the same active drug to include Otezla and state "tofacitinib products"; generic tofacitinib is expected to come to market in 2026. DIRA: Added requirement to confirm a mutation in the IL1RN gene to keep at parity with IL-1 Inhibitor (Arcalyst) criteria. Per guidelines, Kineret is used to induce remission and Arcalyst is used for maintenance of remission; patients would need to meet this requirement when switching to Arcalyst, therefore it is best to also include it for Kineret requests. Cosentyx 300 mg: Updated requirements to align with FDA labeled dosing recommendations and to only include requirements that should be assessed via PA criteria versus QL criteria. (see Discussion Issues During Review below for additional information) JAK inhibitors: Added requirement to confirm the benefits outweigh the risks in patients 50 years of age or older with 1+ cardiovascular risk factor(s); based on Boxed Warning from FDA labeling. (see Discussion Issues During Review below for additional information) Added "induction therapy" callout to approval length notes on Initial Evaluation for clarity and consistency; adalimumab for UC and Siliq for PS. Will assist in question set automation building. Added Exdensur and tofacitinib to "Agents NOT to be used Concomitantly" table. Enbrel 25 mg prefilled syringe (GPI: 6629003000E525): Corrected quantity to 2 mL per 28 days. Previously set up as 2.04 mL per 28 days due to an obsolete product (obsolete date 8/17/21) having a quantity of 0.51 mL. Humira (GPI: 6627001500F520): Removed Humira CD/UC/HS starter pack (NDC: 00074433906) due to going obsolete 4/3/26. Converted from NDC level setup to GPI-14 setup since there will only be one active NDC (00074433902). Humira (GPI: 6627001500F540): Remove NDC level entry for Humira Pediatric UC Starter kit (NDC: 00074012404) due to going obsolete 5/1/26. Other NDC level entries for this GPI-14 are still active. Orencia (GPI: 6640001000E520): Removed GPI-12 NDC level entry and updated to GPI-14 setup. There is only one product available at this GPI-14, and the other GPIs within the GPI-12 are already set up at GPI-14.	7/1/26	5/4/26
myprime.com	Calcitonin Gene-Related Peptide (CGRP)	UPDATE	*Changed length of approval to the new default approval lengths per regulations (12 months for all indications).	7/1/26	5/4/26
myprime.com	Camzyos	UPDATE	March Ad-Hoc Program name changed to Cardiac Myosin Inhibitors to allow Myqorzo to be added as a target. Clinical requirements in initial and renewal criteria updated to align with the FDA labeling.	7/1/26	5/4/26
myprime.com	Cannabidiol	UPDATE	Added quantity limit of 1000 mLs per 30 days and removed FDA dose check. Added another FDA labeled indication pathway to allow for assessing any future indications prior to criteria being updated. *Added compendia supported indication allowance based on client feedback and listed the standard allowed compendia sources.	7/1/26	5/4/26
myprime.com	Cibinqo	UPDATE	JAK inhibitors: Added requirement to confirm the benefits outweigh the risks in patients 50 years of age or older with 1+ cardiovascular risk factor(s); based on Boxed Warning from FDA labeling. Added Exdensur and tofacitinib to "Agents NOT to be used Concomitantly" table.	7/1/26	5/4/26
myprime.com	Constipation Agents	UPDATE	Added "and sex (e.g., lubiprostone is FDA labeled for IBS-C in females only)" to preferred wording requirements as lubiprostone is not FDA labeled for IBS-C for men and cannot be offered as a preferred agent. Added "(female use only)" after lubiprostone and Amitiza for the diagnosis of IBS-C in the Preferred/Non-Preferred/Indications table at the top of the PA criteria. *Termed obsolete GPI for Methylnaltrexone Bromide Inj 8 MG/0.4ML GPI: 52580050102015.	7/1/26	5/4/26
myprime.com	Continuous Glucose Monitor (CGM)	UPDATE	Updating program to remove step therapy criteria and add new prior authorization criteria based on new 2026 American Diabetes Association guidelines that indicate that everyone with diabetes should be offered CGMs as an option to monitor blood glucose. Addition of Smart Edit program with the Smart Edit tab. Added PRAC groups for Smart Edit program. Added auto-continuation PRAC group for the PA program which allows any Freestyle product to auto continue itself at an NDC level, same for Dexcom. Addition of secondary NDCs: 57599083501, 57599084401, 57599082001 as PAQL targets. Addition of repack NDCs: 50090629000, 50090636400, 50090638500, 50090643000, 50090724800, 50090636600, 50090629200, 50090710000, 50090636500, 50090642900 as PAQL targets.	7/1/26	5/4/26
myprime.com	Erectile Dysfunction - PDE5 Inhibitors	UPDATE	*Changed program name from "Erectile Dysfunction - Phosphodiesterase Type 5 Inhibitors" to "Erectile Dysfunction - PDE5 Inhibitors".	7/1/26	5/4/26
myprime.com	Familial Chylomicronemia Syndrome (FCS)	UPDATE	Program name change from Tryngolza to Familial Chylomicronemia Syndrome (FCS). Addition of target agent Redemplo (GPI 3090627030E530) with a QL of 1 syringe/84 days. Addition of preferred/non-preferred table and criteria to require use with preferred Redemplo per contracting. Added criteria to confirm use that the requested agent will be used in combination with a low-fat diet from FDA labeling and defined low fat to be less than 20 g of fat per day from clinical trials. Updated specialist examples to include gastroenterologist and remove geneticist. Changed length of approval to the new default approval lengths per regulations.	7/1/26	5/4/26
myprime.com	Fintepla	UPDATE	*Aligned criteria prohibiting monotherapy use with Cannabidiol program for consistency.	7/1/26	5/4/26
myprime.com	Galafold	UPDATE	*Changed length of approval to the new default approval lengths per regulations.	7/1/26	5/4/26
myprime.com	Gondadotropin Hormones	UPDATE	*Update to QL value, 7.5ml to 7.2ml, for Gonal-f GPIs: 3006203005D239, 3006203005D224, 3006203005D224 to align with 2025 package update.	7/1/26	5/4/26
myprime.com	Growth Hormone	UPDATE	March Ad Hoc Sogroya was approved for three new indications that Skytrofa is not yet approved for, so a pathway to bypass the preferred agent was added to the preferred long-acting step requirements for the Child Long-Acting Module. Clinical requirements for the new indications were also added to the Child Long-Acting Module.	7/1/26	5/4/26
myprime.com	Harliku	UPDATE	Added suggestive clinical features to the diagnostic criteria to align with current diagnostic recommendations. Added genetic testing as an allowable diagnostic pathway to align with current recommendations. Added requirement of medical records for prerequisite related criteria. Changed length of approval to the new default approval lengths per regulations (from 6 months to 12 months).	7/1/26	5/4/26
myprime.com	HSDD	UPDATE	March Ad Hoc *Addyi was approved for use in pre and menopausal women, requiring an update to the requirements for Addyi to allow for coverage of the new patient population.	7/1/26	5/4/26
myprime.com	Imcivree	UPDATE	Added genetic confirmation as an accepted diagnostic pathway for BBS. With expansion of the labeled age range to patients as young as 2 years, some affected individuals may not yet exhibit the clinical phenotype despite having the underlying condition. Added allowance for additional FDA-labeled indications to ensure the criteria framework allows for future label expansions (e.g., acquired hypothalamic obesity). Standardized pediatric pharmacotherapy initiation to a >=95th percentile threshold across indications. Removing diagnosis-specific thresholds aligns with general pediatric obesity definitions, simplifies criteria, and maintains an appropriate eligibility floor. Removed criteria distinguishing newly initiated versus established therapy, that included continuation and discontinuation parameters no longer supported by current FDA labeling. Standardized renewal criteria assessing clinical benefit. Previous diagnosis- and age-specific percentage requirements were replaced with a consistent threshold reflecting pharmacotherapy response (>= 5% reduction) that aligns with established obesity guidelines. Added a pathway for assessing clinical benefit in patients outside of POMC/PCSK1/LEPR/BBS, to align with standard template language. *Changed length of approval to the new default approval lengths per regulations.	7/1/26	5/4/26
myprime.com	Interleukin (IL)-1 Inhibitors	UPDATE	RP: Updated prerequisite requirements based on new ACC 2025 and ESC 2025 guidelines for RP. Includes the removal of the required step through a corticosteroid and removal of duration of therapy. Will now require failure of colchicine plus NSAID/ASA (no required duration), intolerance/hypersensitivity/CI to ALL NSAIDS and aspirin, corticosteroid-dependence, or intolerance/hypersensitivity/CI to colchicine. (see Discussion Issues During Review below for additional information) Updated prescriber specialist requirement to list specialty examples for each specific indication to aid reviewers. *Added Exdensur and tofacitinib to "Agents NOT to be used Concomitantly" table.	7/1/26	5/4/26
myprime.com	Interleukin (IL)-4 Inhibitors	UPDATE	CRSwNP: Updated CRS symptoms requirement to have separate adult and pediatric patient pathways due to differences in symptoms between the age populations; hyposmia (adult) and cough (pediatric). Added Exdensur and tofacitinib to "Agents NOT to be used Concomitantly" table.	7/1/26	5/4/26
myprime.com	Interstitial Lung Disease (ILD)	UPDATE	Added new criteria to the Initial Evaluation for Jascayd that is consistent with its expanded indication for PPF, which requires evidence of disease progression in at least two of three clinical domains (symptoms, physiology, or imaging) within the prior year, with exclusion of alternative causes of disease worsening. These requirements align with existing criteria for Ofev in the setting of progressive fibrotic ILD. Added step-through antifibrotic therapy requirements to the Initial Evaluation criteria for Jascayd in IPF, requiring use as add-on therapy to established antifibrotic treatment or allowing monotherapy when there is a clinical reason that background antifibrotic therapy is not appropriate. This update aligns access to Jascayd with guideline-directed antifibrotic therapy for IPF while preserving monotherapy use consistent with Jascayd clinical trials.	7/1/26	5/4/26
myprime.com	Joenja	UPDATE	Genetic testing criterion was updated to specify "pathogenic or likely pathogenic" variants, due to expanded genomic testing that can occasionally identify benign or incidental variants that are not disease-causing or indicative of treatment eligibility. Genetic testing criterion was updated to specify variants "in PIK3CD and/or PIK3R1" (rather than "in either PIK3CD or PIK3R1"), aligning language with current APDS classification and avoiding ambiguity regarding qualifying genes. Changed length of approval to the new default approval lengths per regulations. Removed QL criteria that allowed for dosing to exceed FDA max, reflecting that Joenja has a single, fixed-dosing regimen with no evidence supporting dose escalation beyond labeled use.	7/1/26	5/4/26
myprime.com	Jynarque	UPDATE	Added Continuation of Therapy (CoT) criteria as the indications for the target agents are chronic/non-curative. Standardized CoT to allow patients already on therapy to bypass additional PA requirements (e.g., age criteria) and grouped age criteria with the FDA labeled indications. *Removed "for the requested indication" from criteria disallowing concomitant use with another tolvaptan agent to align with FDA labeling for both Jynarque and Samsca.	7/1/26	5/4/26
myprime.com	LMWH-Arixtra	UPDATE	*Termed for Comm/HIM/NR.	7/1/26	5/4/26
myprime.com	Lupus	UPDATE	Removed criteria "If patient has a diagnosis other than active SLE or active LN" from Renewal criteria and, instead, added "If/then" to the beginning of the previous diagnoses criteria. Added Exdensur to "Agents NOT to be used Concomitantly" table.	7/1/26	5/4/26
myprime.com	Northera	UPDATE	*Termed for Comm/HIM/NR.	7/1/26	5/4/26
myprime.com	Opioid IR MME	UPDATE	Updated tapentadol MME conversion factor from 0.3 to 0.4 to be consistent with 2022 CDC guidelines. Removed obsolete agent Apadaz (benzhydrocodone/apap) tablet GPIs: 65990002020330, 65990002020320, 65990002020310.	7/1/26	5/4/26
myprime.com	Oral NSAID	UPDATE	*Removed the following obsolete brand name drugs as target agents: Feldene (GPI 661000700001) and Zorvolex (GPI 661000070001).	7/1/26	5/4/26
myprime.com	Otezla	UPDATE	Moved weight requirements to apply to all requests on Initial Evaluation, including CoT pathway, per standardization. Psoriasis: Updated phototherapy prerequisite to list PUVA and UVB as possible examples. BD: Updated requirement of 3 occurrences of oral ulcers to allow them during any previous 12-month period to appropriately follow International Study Group (ISG) diagnostic criteria. BD: Updated conventional agent prerequisites to only include systemic agents to more appropriately follow guideline treatment algorithms for apremilast's place in therapy. *Added Exdensur and tofacitinib to "Agents NOT to be used Concomitantly" table.	7/1/26	5/4/26
myprime.com	Oxybate	UPDATE	Removed “Sodium Oxybate” from Xyrem entry in FDA table due to change from MSCM to MSCY. Changed Xyrem brand/generic criteria from “authorized generic Sodium Oxybate” to “generic sodium oxybate” due to MSC change. Termed GPI 62450060. Created GPI 624500602030, 6245006020B1, 624500602020 (targeted MSCO), and 624500602020 (MSCM, N, and Y) for Smart Edit implementation. Smart Edit: addition of Smart Edit Group #1 information that includes prerequisites, continuation of therapy, and diagnosis of narcolepsy (ICD10- G47.41). Smart Edit: addition of Smart Edit Group #2 information that includes prerequisites, continuation of therapy, and diagnosis of narcolepsy (ICD10- G47.41) for MSCO Xyrem criteria.	7/1/26	5/4/26
myprime.com	Pulmonary Arterial Hypertension	UPDATE	PH associated with interstitial lung disease (ILD) - Added an option for patients that are not candidates for right heart catheterization to bypass confirmation of their diagnosis. This is based on guidelines and specialist recommendation. PH-ILD - Removed requirement that patients be on standard of care for ILD. It is not a requirement per FDA labeling for the requested agent and it can be inferred that the specialists treating these patients have them on all necessary standard of care therapy. *Tyvaso DPI Titration kit (GPI 40170080002970) termed due to going obsolete April 2026.	7/1/26	5/4/26
myprime.com	SA Oncology	UPDATE	Added the drugs Danziten, Nilotinib d-tartrate, and nilotinib (generic) to the criteria point within the preferred/non-preferred section along with Tasigna and Bosulif to mirror the preferred/non-preferred table and to allow continuation of therapy for CML if previously treated with these agents. Removed Phyrago from the brand/generic equivalent table into its own criteria point to require step through generic dasatinib as dasatinib is not a generic equivalent (MSC Y) to Phyrago. *Removed directions for approving titration requests from the Length of Approval as downstream Clinical Operations already has their own internal process for titration requests across all programs.	7/1/26	5/4/26
myprime.com	Samsca	UPDATE	Added criteria points to assess for another FDA labeled indication or compendia supported indications to provide a review path downstream along with a more specific denial reason for Clinical Operations for off-label indications and specified the standard allowed compendia sources. Rearranged the criteria to lead with the diagnosis of hypervolemic or euvolemic hyponatremia and moved all criteria points specific to this indication under it. Removed "for the requested indication" from criteria disallowing concomitant use with another tolvaptan agent to align with FDA labeling for both Jynarque and Samsca. Length of Approval was decreased from 12 months to 6 months for hyponatremia to align with new default approval lengths per regulations for acute indications. Added a length of approval of 12 months for all other indications that are not hyponatremia. Added the standard Universal QL criteria for all indications that are not hyponatremia. *Updated QLs from #30 tabs (15 mg) and #60 tabs (30mg) per 12 months down to #30/6 months and #60/6 moths to align with the updated length of approval.	7/1/26	5/4/26
myprime.com	Spevigo	UPDATE	Updated wording for the requirement: There is support for the use of combination therapy (submitted copy of clinical trials, phase III studies, or guidelines required) to align with wording from other programs. Previously this wording had in "support required, i.e.," which was the piece replaced. Removed "Please refer to" and substituted with "Per" based on wording from other similar programs when referring to the contraindications table. *Added Exdensur (depemokimab-ulaa) to the contraindications table.	7/1/26	5/4/26
myprime.com	Subcutaneous Furosemide	UPDATE	Program name change from "Furoscix (furosemide)" to "Subcutaneous Furosemide". Addition of target Lasix Onyu with a QL of 8 kits per 180 days to align with QL of Furoscix. Split out the indications for chronic heart failure and chronic kidney disease (CKD) so that CKD could be approvable only for Furoscix due to FDA labeling differences between targets. Removed requirement for total daily dose of furosemide equivalent as it is not applicable to trial inclusion criteria for both targets. Added criteria to ensure agents will not be used chronically and removed concomitant use with another loop diuretic. Adjusted language for transitioning back to oral diuretics as soon as practical to follow verbiage used in the prescribing information. Added criteria to ensure patient is a candidate for outpatient treatment. Decreased length of approval from 12 months to 6 months to align with new default approval lengths per regulations for acute indications.	7/1/26	5/4/26
myprime.com	Substrate Reduction Therapy	UPDATE	Cerdelga and Zavesca modules: Removed "baseline" wording from the glucocerebrosidase enzyme activity criterion because enzyme activity does not represent a treatment-anchored or time-dependent baseline measurement, even for patients newly initiating therapy. Updated the glucocerebrosidase enzyme activity requirement from a fixed numeric cut-off (<=15%) to a lab-interpreted standard ("deficient"), preserving diagnostic intent while improving alignment with current patient-centered diagnostic guidance and real-world lab reporting. Changed GBA genetic criterion wording from "two pathogenic alleles" to "biallelic pathogenic variants". Removed the neuronopathic symptom exclusion criterion to align with updated literature noting that neurologic/CNS-associated findings may occur in patients with GD1, and that neurologic findings alone should not be used to reclassify patients as GD2 or GD3. Updated hematologic criteria language to reflect lab-specific reference ranges in clinical practice. Anemia and thrombocytopenia thresholds were generalized to rely on the testing lab's reference range rather than a single universal numeric cut-off. All modules: Expanded the non-concurrent use criterion to disallow combination use with other Gaucher disease-specific agents (including ERT in addition to SRT), consistent with treatment sequencing and the lack of evidence supporting combination therapy.	7/1/26	5/4/26
myprime.com	Sunosi	UPDATE	*Specialist requirement no longer a requirement for excessive daytime sleepiness associated with obstructive sleep apnea (OSA) in initial and renewal criteria.	7/1/26	5/4/26
myprime.com	Tavneos	UPDATE	*Length of approval updated per guidance.	7/1/26	5/4/26
myprime.com	Tezspire	UPDATE	CRSwNP: Updated CRS symptoms requirement to have separate adult and pediatric patient pathways due to differences in symptoms between the age populations; hyposmia (adult) and cough (pediatric). Added Exdensur and tofacitinib to "Agents NOT to be used Concomitantly" table.	7/1/26	5/4/26
myprime.com	TPO-RA, Tavalisse and Wayrilz	UPDATE	Name of Program shorten to "TPO-RA, Tavalisse and Wayrilz". Initial Criteria: Reworded concomitant use verbiage with Nplate with another TPO-RA for HS-ARS to better convey intent. Renewal Criteria: 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. Initial Doptelet ITP Criteria: Reworded pediatric persistent condition for clarification. Initial Nplate ITP Criteria: Added an option for adult and reworded pediatric criterion for clarification. Initial and Renewal Criteria: Added specialist criteria requirement. *For the diagnosis of ITP, for criteria that asks, “the patient has tried and had an inadequate response to another thrombopoietin receptor agonist or tyrosine kinase inhibitor,” Wayrilz was added to Doptelet and Tavalisse sections, and Tavalisse was added to Wayrilz section.	7/1/26	5/4/26
myprime.com	Triptan (Migraine)	UPDATE	Added "generic meloxicam taken in combination with another generic triptan prerequisite agent" to Symbravo double step therapy to make intent clear that requirement is that two different combinations required to meet criteria. Updated order of prerequisites asked in criteria to match order presented in table. Updated table to remove plus symbol in exchange for "AND" and changed "agents" to "triptans" to be more policy specific. For consistency, removed "Reyvow" as example of 5HT-1F since we do not provide other examples for triptan and ergotamine agents.	7/1/26	5/4/26
myprime.com	Verkazia	UPDATE	*Addition of new Verkazia NDC: 82667001401 to PAQL. Update policy to GPI level set-up.	7/1/26	5/4/26
myprime.com	Vijoice	UPDATE	Clarified mutation language to include "activating" in regard to the somatic PIK3CA mutation to ensure coverage is limited to pathogenic variants driving PROS, rather than incidental (non-activating) findings. Removed "sporadic and mosaic" from diagnostic criteria, as these characteristics are inherent to PROS resulting from a somatic PIK3CA mutation and do not require separate (redundant) confirmation. Removed "congenital or early childhood onset" from diagnostic criteria, as PROS is present from early development. Removing this criterion also reduces the risk of inappropriate denials in cases where congenital onset was not fully noted in patient's history/records. Removed the renewal requirement that the patient has not had disease progression (documented by lack of increase in lesion number or volume), as guidance supports assessing ongoing treatment based on patient clinical benefit rather than trial-specific radiographic measures, which are not standardized or universally applicable in PROS. *Changed length of approval to the new default approval lengths per regulations.	7/1/26	5/4/26
myprime.com	Weight Loss Agents	UPDATE	*Removed the following targets and any formulations from the policy due to their CTL-3 status: benzphetamine, phendimetrazine, diethylpropion.	7/1/26	5/4/26
myprime.com	Weight Management	UPDATE	Addition of general wording to ensure FDA labeled use for each set of diagnosis requirements: "The patient has an FDA labeled indication for the requested agent and route of administration AND ONE of the following:". This allows more flexibility and fewer updates with future products and indications which may be added to the criteria. Removed the specific agent called out in each requirement section (e.g., Zepbound in OSA, Wegovy injection in MASH requirements) due to new addition of FDA labeled statement.	7/1/26	5/4/26
02.01.050	Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders	UPDATE	Clinical evidence to support the policy position was reviewed. There is no change to the policy position statement listed.	6/29/26	4/27/26
05.01.047	Gene Therapies for Treatment of Wounds in Dystrophic Epidermolysis Bullosa (Vyjuvek)	UPDATE	Updated policy information, including updated policy position information.	6/22/26	4/20/26
02.04.095	Human Leukocyte Antigen Testing for Celiac Disease	UPDATE	Clinical evidence to support the policy position was reviewed. There is no change to the policy position statement listed.	6/22/26	4/20/26
02.04.096	Genetic Testing for Statin-Induced Myopathy	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	6/22/26	4/20/26
12.01.093	Injectable and Health Care Administered Oncology	UPDATE	Added preferred product information. Preferred products for Trastuzamab are: Kanjinti and Ogivri.	6/15/26	4/13/26
06.01.051	Interim Positron Emission Tomography Scanning in Oncology to Detect Early Response During Treatment	UPDATE	Clinical evidence to support the policy position was reviewed and references added. Split lymphoma PICO to 2 PICOs - Hodgkin and non-Hodgkin. Medically necessary policy statement added for advanced Hodgkin lymphoma.	6/8/26	4/13/26
06.01.061	Oncologic Applications of Positron Emission Tomography Scanning (Gastrointestinal and Pancreatic)	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	6/8/26	4/13/26
06.01.062	Oncologic Applications of Positron Emission Tomography Scanning (Breast and Gynecologic)	UPDATE	Clinical evidence to support the policy position was reviewed and references added. Significant editorial refinements to policy statements; intent unchanged.	6/8/26	4/13/26
06.01.063	Oncologic Applications of Positron Emission Tomography Scanning (Bone and Sarcoma)	UPDATE	Clinical evidence to support the policy position was reviewed and references added. Significant editorial refinements to policy statements; intent unchanged.	6/8/26	4/13/26
06.01.064	Oncologic Applications of Positron Emission Tomography Scanning (Hematologic)	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	6/8/26	4/13/26
06.01.065	Oncologic Applications of Positron Emission Tomography Scanning (Lung)	UPDATE	Clinical evidence to support the policy position was reviewed and references added. Editorial revision throughout policy related to use of guidelines. Intent of policy statements unchanged.	6/8/26	4/13/26
06.01.066	Oncologic Applications of Positron Emission Tomography Scanning (Thyroid, Neuroendocrine, Head and Neck)	UPDATE	Clinical evidence to support the policy position was reviewed. Significant editorial refinements to policy statements; intent unchanged.	6/8/26	4/13/26
06.01.067	Oncologic Applications of Positron Emission Tomography Scanning (Brain, Melanoma, Unknown Primary)	UPDATE	Clinical evidence to support the policy position was reviewed. Significant editorial refinements to policy statements; intent unchanged.	6/8/26	4/13/26
02.04.141	Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy)	UPDATE	Clinical evidence to support the policy position was reviewed and references added. Three PICOs were removed as they are represented in other reference medical policies. There is no change to the policy position statement listed.	6/1/26	3/30/26
02.04.019	Pharmacogenomic and Metabolite Markers for Patients Treated with Thiopurines	UPDATE	Clinical evidence to support the policy position was reviewed and guidelines updated. Minor editorial refinements to policy statements, including title change; intent unchanged.	6/1/26	3/30/26
02.04.033	Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer	UPDATE	Clinical evidence to support the policy position was reviewed and references added. Added MiCheck prostate test. There is no change to the policy position statement listed.	6/1/26	3/30/26
02.04.084	Measurement of Serum Antibodies to Selected Biologic Agents	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	6/1/26	3/30/26
12.01.013	Hemophilia Factor VIII - Advate, Adynovate, Afstyla, Eloctate, Kogenate FS/Helixate FS, Kovaltry, NovoEight, Nuwiq, Recombinate, Xyntha, Hemofil M, Monoclate-P	UPDATE	Updated policy information, including updated policy position information. Updated title to Hemophilia Factor VIII.	6/1/26	3/30/26
02.01.080	Endoscopic Radiofrequency Ablation or Cryoablation for Barrett Esophagus	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	5/25/26	3/23/26
02.01.091	Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia and Gastroparesis	UPDATE	Clinical evidence to support the policy position was reviewed and references added. There is no change to the policy position statement listed.	5/25/26	3/23/26
myprime.com	Interstitial Lung Disease	UPDATE	Added new criteria to the Initial Evaluation for Jascayd that is consistent with its expanded indication for PPF, which requires evidence of disease progression in at least two of three clinical domains (symptoms, physiology, or imaging) within the prior year, with exclusion of alternative causes of disease worsening. These requirements align with existing criteria for Ofev in the setting of progressive fibrotic ILD. Added step-through antifibrotic therapy requirements to the Initial Evaluation criteria for Jascayd in IPF, requiring use as add-on therapy to established antifibrotic treatment or allowing monotherapy when there is a clinical reason that background antifibrotic therapy is not appropriate.	6/1/26	3/16/26
05.01.045	Gene Therapies for Cerebral Adrenoleukodystrophy (Skysona)	NEW	Implementation of NEW guidelines.	5/15/26	3/16/26
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
02.01.061	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
12.01.006	Colony Stimulating Factors - Fulphila, Fylnetra, Granix, Leukine, Neulasta, Neupogen, Nivestym, Nypozi, Nyvepria, Releuko, Rolvedon, Stimufend, Udenyca, Zarxio, Ziextenzo	UPDATE	Updated policy information, including updated policy position information. Added preferred products of Fulphila or Udenyca On Body.	1/1/26	10/28/25
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

ASC Reimbursement Update

Blue Cross Blue Shield of Wyoming is committed to providing you with updates on upcoming policy and reimbursement changes. Effective, 9/1/24, BCBSWY is updating our ASC rates and rules. ASC rates can be found in the Availity portal under the BCBSWY payer space.

BCBSWY Prior Authorization Webinars

We encourage you to register for an upcoming webinar that is specific to the changes we’re implementing starting July 1 for how we notify you of medical policy updates and transfer prior authorization requests. These new processes are intended to ease the administrative burdens for providers and members for prior authorization requests as required by the recent state legislation, HB0014 Ensuring Transparency in Prior Authorization Act.

We are offering two options that will cover the same content in both sessions and registration is required.

Prior Authorization Enhancements Webinar

Wed., 6/12 12:00-1:00 pm

Prior Authorization Enhancements Webinar

Tues., 6/18, 12:00-1:00 pm

Medical Policy Update

Prior Authorization Submission Reminder

BCBSWY is committed to improving communication and knowledge of medical policy updates. Effective 9/1/2024, BCBSWY will implement a new medical policy specific to Home Infusion services. Please review the below information for an overview of this policy.

Definition

Home infusion is the administration of medications or nutrition intravenously in a patient’s home or office. Home infusion services must be ordered in writing by a physician.

Documentation must identify and describe the services performed including total time of the service. Appeals submitted without this documentation will be rejected.

Payment for HIT Services

The HCPCS “G” codes for home infusion services are to be used for billing. Billing for “G” codes includes professional services, including nursing services, furnished in accordance with care coordination, patient training and education, remote monitoring, and monitoring services for the provision of home infusion therapy.

Infusion pumps, home infusion drugs, other supplies, are to be billed separately. A G-code is billed for each day that a patient receives an infusion and services are rendered in person from the provider.

Home infusion therapy (HIT) is billed based upon type:

Intravenous infusion
Subcutaneous infusion
Intravenous chemotherapy or complex drug.

Billing for each code type is differentiated based upon “first visit” status. A visit is considered a first visit when it has been at least 60 days since a patient has received any home infusion therapy services billed with a G code.

All HIT services require at least one non-oral drug or biological to be billed alongside the G code. This drug determines the type mentioned above.

Code	Description	Visit Type
G0068	Administration of Intravenous infusion drug in home	General Visit
G0069	Administration of Subcutaneous infusion drug in home
G0070	Administration of Intravenous chemotherapy or other complex drug in home
G0088	Administration of Intravenous infusion drug in home	1^st Visit
G0089	Administration of Subcutaneous infusion drug in home
G0090	Administration of Intravenous chemotherapy or other complex drug in home

Services billed with G-codes will only be reimbursable when services are rendered in person in the patient’s home. Provision of medications and remote support alone is not sufficient for a provider to be eligible for HIT reimbursement.

Other HIT Services with Different Guidelines from the Above

Enteral and Parenteral Nutrition Infusions

The HCPCS “S” codes for enteral and parenteral nutrition home infusion services are based on a “per diem” reimbursement methodology (S9341 – S9343, S9364 – S9368). The per diem includes all supplies, care coordination and professional pharmacy services. The per diem code is billed for each day that a patient receives an infusion, and services are rendered in person from the provider. Other nursing services and drug products are billed separately from the per diem.

Reimbursement is allowed separately for the following supplies: ambulatory infusion pumps (E0779-E0781). BCBSWY may allow separate reimbursement for other supplies on a case-by-case basis.

Per diems will only be reimbursable when services are rendered in person in the patient’s home. Provision of medications and remote support alone is not sufficient for a provider to be eligible for per diem reimbursement.

Catheter Care

Bill catheter care per diems (S5497, S5498, S5501, S5502) when provided as a stand-alone therapy. Insertion by a nurse of a PICC line (S5522) or midline (S5523) is coded separately from the other nursing visit codes and per diems. Supplies required from non-routine catheter procedures such as de-clotting supplies (S5517), repair kits (S5518), PICC insertion supplies (S5520) and midline insertion supplies (S5521) are coded separately.

Hydration Therapy

Bill hydration therapy per diems (S9373-S9377) when provided as a stand-alone therapy.

Other Payments

Providers who do not render in-person infusions and are not eligible to be reimbursed a per diem or “G” code may still be eligible to be reimbursed for supplies as detailed below.

Medical Supplies

Medical supplies that are consumable, expendable, disposable, or non-durable and that are used for treatment of a patient’s specific illness, injury, may be reimbursed separately using the appropriate HCPCS code.

Drugs

Drugs should be billed with a HCPCS or CPT code. If a specific code is not available, providers should use J3490, J3590, J7799, or J9999 along with narrative, NDC number, dosage and units supplied. Related NDC codes for compounded products are itemized using the LIN and CTP segments on the 837P claim format. These claims may require manual review.

Multiple Therapies

If multiple therapies that would be billed using a per diem S code are done on the same date of service, append the following modifiers to the per diem S codes:

SH – Second concurrently administered infusion therapy
SJ – Third or more concurrently administered therapy

Only one G code is reimbursable each day. If two or more home infusion drugs or biologicals from two (or more) different payment categories are administered to an individual concurrently on a single infusion calendar day, one payment.

If both a service billed using a per diem and service billed using a G code are performed on the same day both codes should be submitted. Payment will only be made for the G code.

Claim Form

Home Infusion Therapy (HIT) providers should submit claims for services on HCFA 1500 or 837p.

Stay Informed: Register below for an upcoming prior authorization webinar to learn how BCBSWY will communicate new medical policies and updates beginning 7/1/24.

BCBSWY Prior Authorization Webinars

BCBSWY supported the recent legislation, HB0014 Ensuring Transparency in Prior Authorization Act, and worked with stakeholders to adopt policies intended to ease the administrative burdens for providers and members for prior authorization requests.

These upcoming webinars will help you become familiar with new processes to ease your prior authorization requests. We are offering two options that will cover the same content in both sessions.

Prior Authorization Enhancements Webinar

Wed., 6/12 12:00-1:00 pm

Prior Authorization Enhancements Webinar

Tues., 6/18 12:00-1:00 pm

Blue Cross Blue Shield of Wyoming will be closed on Monday, May 27 in observance of Memorial Day. Regular business hours will resume on Tuesday, May 28.

Reimbursement Update May 16-2024

Prior Authorization Submission Reminder

Providers should be using the online prior authorization submission portal in Availity. It is now live and fully accessible.

To report any issues related to errors during submission, please call 1-888-666-5188. Our Provider Relations Team will ask you to collect a screenshot of the error including the web address bar and the clock in the bottom right-hand corner of your screen. They will provide you an email address for submission. This will allow our technical teams to validate the issue. Your feedback is critical as we make technical improvements and streamline this process.

Currently, BCBSWY will only accept faxed authorizations for the following:

· FEP Membership (Contract number has an alpha prefix of “R”)

· Residential Treatment Center

· Skilled Nursing Facilities

· Acute Rehabilitation Facilities

· Long Term Acute Care Facilities

· Swing Bed

· Transplant Authorizations

In an effort to prepare for implementation of the 7/1 Prior Authorization Wyoming state legislation, BCBSWY will start requiring the following authorizations to be submitted through Availity effective 6/1/24.

· Residential Treatment Center

· Skilled Nursing Facilities

· Acute Rehabilitation Facilities

· Long Term Acute Care Facilities

· Swing Bed

BCBSWY Prior Authorization Enhancements

These upcoming webinars will help you become familiar with new processes to ease your prior authorization requests. We are offering two options that will cover the same content in both sessions.

Prior Authorization Enhancements Webinar

Wed., 6/12 12:00-1:00 pm

Prior Authorization Enhancements Webinar

Tues., 6/18 12:00-1:00 pm

Reimbursement Update

Effective August 1, 2024, Blue Cross Blue Shield of Wyoming will be implementing new rates for all radiology services to align with the Resource-Based Relative Value Scale (RBRVS) payment system.

Rates for individual codes may increase or decrease as we work to make them consistent with the RBRVS. Overall, we estimate that adjusting rates to the RBRVS for these services will result in a net neutral reimbursement change.

Upcoming Provider Webinars

As part of Blue Cross Blue Shield of Wyoming’s ongoing commitment to improve the prior authorization process, we are offering three educational webinars to assist our provider community.

The first webinar will include more helpful tips regarding Predictal and the prior authorization submission process in addition to a question-and-answer portion to help providers improve their understanding of this tool.

Register Now

BCBSWY Prior Authorization Enhancements

These upcoming webinars will help you become familiar with new processes to ease your prior authorization requests. We are offering two options that will cover the same content in both sessions.

Prior Authorization Enhancements Webinar
Wed., 6/12 12:00-1:00 pm

Register Now

Prior Authorization Enhancements Webinar
Tues., 6/18 12:00-1:00 pm

Register Now

Upcoming Provider Webinars

As part of Blue Cross Blue Shield of Wyoming’s ongoing commitment to improve the prior authorization process, we are offering three educational webinars to assist our provider community.

Our Provider Relations Team will ask you to collect a screenshot of the error including the web address bar and the clock in the bottom right-hand corner of your screen. They will provide you an email address for submission. This will help our technical team to validate the issue.

Predictal Webinar

Wed., 5/15 12:00-1:00 pm

Register Now

BCBSWY Prior Authorization Enhancements

These upcoming webinars will help you become familiar with new processes to ease your prior authorization requests. We are offering two options that will cover the same content in both sessions.

Prior Authorization Enhancements Webinar

Wed., 6/12 12:00-1:00 pm

Register Now

Prior Authorization Enhancements Webinar

Tues., 6/18 12:00-1:00 pm

Register Now

Prior Authorization Procedure Update

Beginning 5/6/24, BCBSWY will no longer require prior authorization on the following cardiac ablation procedures:
CPT CODE: 93613, 93655, 93656, 93657, 93662, 33250, 33521, 33261, C1730, C1731, C1732, C1733, C1759, C1766, C1887, C1892, C1893, C2630
However, BCBSWY will continue to require authorization on cardiac ablation with reconstruction of the atria (i.e. MAZE or modified MAZE procedures).

Prior Authorization Portal Update

Announcements

Prior Authorization Portal Update

Providers should begin using the online prior authorization submission portal in Availity. It is now live and fully accessible.

If you encounter any issues, please don’t hesitate to reach out to our Provider Relations team for assistance. We appreciate our Providers who have been able to
provide helpful feedback during this time.

Effective 4/29/2024, BCBSWY will resume not accepting faxed authorizations except for the following:

FEP Membership (Contract number has an alpha prefix of “R”)
Residential Treatment Center
Skilled Nursing Facilities
Acute Rehabilitation Facilities
Long Term Acute Care Facilities
Swing Bed
Transplant Authorizations

To report any issues related to errors during submission, please call 1-888-666-5188.

Need Help? Please visit our website for submission instructions here.

Good Habits

Provider Directory Validation Reminder

You can find the Provider Directory Validation guide under the Provider Resources section on the right rail of the website.

Providers can use the Directory Validation tool on the Availity Portal to find NPI and tax ID combinations.

The No Surprises Act (NSA) requires you confirm this information every 90 days.

Confirm Today

FEP PRIOR AUTHORIZATIONS

IMPORTANT DATES

Provider Directory Validation Reminder

Provider Directory Validation Reminder

Prior Authorization Tip

Reimbursement Update

Medical policy updates are now available.

Prevent rejection when submitting medical records through Availity

Provider Directory Validation Reminder

Early Closure – Wed. July 24

Medical Policy Updates

Medical Policy Updates

Filters

ASC Reimbursement Update

BCBSWY Prior Authorization Webinars

Prior Authorization Enhancements Webinar

Prior Authorization Submission Reminder

Definition

Payment for HIT Services

Other HIT Services with Different Guidelines from the Above

Catheter Care

Hydration Therapy

Other Payments

Medical Supplies

Drugs

Multiple Therapies

Claim Form

BCBSWY Prior Authorization Webinars

Prior Authorization Submission Reminder

BCBSWY Prior Authorization Enhancements

Prior Authorization Enhancements Webinar

Prior Authorization Enhancements Webinar

Reimbursement Update

Upcoming Provider Webinars

BCBSWY Prior Authorization Enhancements

Prior Authorization Enhancements Webinar Wed., 6/12 12:00-1:00 pm

Prior Authorization Enhancements Webinar Tues., 6/18 12:00-1:00 pm

Upcoming Provider Webinars

BCBSWY Prior Authorization Enhancements

Prior Authorization Procedure Update

Announcements

Prior Authorization Portal Update

Good Habits

Provider Directory Validation Reminder

ACA – Online Event Registration Form

Prior Authorization Enhancements Webinar
Wed., 6/12 12:00-1:00 pm

Prior Authorization Enhancements Webinar
Tues., 6/18 12:00-1:00 pm