|
Medical Policy Number
| Medical Policy Name | Effective Date of Change | Description of Changes |
|---|
|
CP.PMN.152 |
Lofexidine (Lucemyra) |
6/01/2025 |
Added redirection to generic lofexidine per SDC request. |
|
HIM.PA.171 |
Insulin detemir (Levemir) |
6/01/2025 |
Added disclaimer that Novo Nordisk discontinued Levemir products; added requirement for provider attestation acknowledging the discontinuation of Levemir products; added Appendix E regarding discontinuation of Levemir products. |
|
CP.PCH.53 |
Leuprolide Acetate (Eligard, Fensolvi, Lupron Depot, Lupron Depot-Ped), Leuprolide mesylate (Camcevi) |
06/01/2025 |
For gender dysphoria and gender transition, added requirement for provider attestation of understanding current State regulations regarding transgender-related health care and such care is coverable under the State regulations, added to Appendix D link and notation that the Movement Advancement Project can be referenced to confirm transgender-related health care is coverable under the State regulations. |
|
CP.PHAR.171 |
Goserelin Acetate (Zoladex) |
06/01/2025 |
For gender dysphoria and gender transition, added requirement for provider attestation of understanding current State regulations regarding transgender-related health care and such care is coverable under the State regulations, added to Appendix D link and notation that the Movement Advancement Project can be referenced to confirm transgender-related health care is coverable under the State regulations. |
|
CP.PHAR.172 |
Histrelin Acetate (Vantas, Supprelin LA) |
06/01/2025 |
For gender dysphoria and gender transition, added requirement for provider attestation of understanding current State regulations regarding transgender-related health care and such care is coverable under the State regulations, added to Appendix D link and notation that the Movement Advancement Project can be referenced to confirm transgender-related health care is coverable under the State regulations. |
|
CP.PHAR.174 |
Nafarelin Acetate (Synarel) |
06/01/2025 |
For gender dysphoria and gender transition, added requirement for provider attestation of understanding current State regulations regarding transgender-related health care and such care is coverable under the State regulations, added to Appendix D link and notation that the Movement Advancement Project can be referenced to confirm transgender-related health care is coverable under the State regulations. |
|
CP.PHAR.175 |
Triptorelin Pamoate (Trelstar, Triptodur) |
06/01/2025 |
For gender dysphoria and gender transition, added requirement for provider attestation of understanding current State regulations regarding transgender-related health care and such care is coverable under the State regulations, added to Appendix D link and notation that the Movement Advancement Project can be referenced to confirm transgender-related health care is coverable under the State regulations. |
|
CP.PHAR.354 |
Testosterone (Testopel, Jatenzo, Kyzatrex, Tlando) |
06/01/2025 |
For gender dysphoria and gender transition, added requirement for provider attestation of understanding current State regulations regarding transgender-related health care and such care is coverable under the State regulations, added to Appendix D link and notation that the Movement Advancement Project can be referenced to confirm transgender-related health care is coverable under the State regulations. |
|
HIM.PA.87 |
Testosterone (Androderm) |
06/01/2025 |
For gender dysphoria and gender transition, added requirement for provider attestation of understanding current State regulations regarding transgender-related health care and such care is coverable under the State regulations, added to Appendix D link and notation that the Movement Advancement Project can be referenced to confirm transgender-related health care is coverable under the State regulations. |
|
CP.PHAR.593 |
Delandistrogene Moxeparvovec-rokl (Elevidys) |
06/01/2025 |
Removed HIM and Commercial lines of business; restricted Elevidys to age to 4 years through 5 years; added member does not have an active infection; added member has all of the following assessed within the last 30 days: stable cardiac function with LVEF ≥ 40%, baseline liver function tests with absence of significant liver dysfunction, and baseline platelet count and baseline troponin I; added disclaimer for non-ambulatory members to refer to Section III; added member has not been previously treated with the investigational agent deramiocel (CAP-1002). |
