| Policy |
Policy Name |
Date Posted |
Date Removed |
| DMP0826-01 |
Aflibercept Products (Eylea®; Eylea®HD, Ahzantive™ [aflibercept-mrbb], Enzeevu™ [Afliberceptabzv], Eydenzelt® [Aflibercept-boav], Opuviz™ [Aflibercept-yszy], Pavblu™ [Aflibercept-ayyh], and Yesafili™ [Aflibercept-jbvf]) |
08/6/26 |
09/6/26 |
| DMP0826-02 |
Avalglucosidase Alfa-ngpt (Nexviazyme™) |
08/6/26 |
09/6/26 |
| DMP0826-03 |
Benralizumab (Fasenra®) |
08/6/26 |
09/6/26 |
| DMP0826-04 |
Bevacizumab Products (Avastin®; Mvasi® ; Zirabev™; Alymsys®; Vegzelma™, Avzivi®, Jobevne™) |
08/6/26 |
09/6/26 |
| DMP0826-05 |
Brolucizumab-dbll (Beovu®) |
08/6/26 |
09/6/26 |
| DMP0826-06 |
Guselkumab (Tremfya®) |
08/6/26 |
09/6/26 |
| DMP0826-07 |
Ipilimumab (Yervoy®) |
08/6/26 |
09/6/26 |
| DMP0826-08 |
Leuprolide acetate (Eligard®, Vabrinty™) |
08/6/26 |
09/6/26 |
| DMP0826-09 |
Leuprolide Acetate (Fensolvi®) |
08/6/26 |
09/6/26 |
| DMP0826-10 |
Leuprolide Suspension (Lupron Depot®, Leuprolide Acetate Depot 1-Month 3.75mg, 3-Month 11.25 mg) |
08/6/26 |
09/6/26 |
| DMP0826-11 |
Mirikizumab-mrkz (Omvoh) |
08/6/26 |
09/6/26 |
| DMP0826-12 |
Nivolumab (Opdivo®) |
08/6/26 |
09/6/26 |
| DMP0826-13 |
Nivolumab and Hyaluronidase-nvhy (Opdivo Qvantig™) |
08/6/26 |
09/6/26 |
| DMP0826-14 |
Pasireotide (Signifor® LAR) |
08/6/26 |
09/6/26 |
| DMP0826-15 |
Ranibizumab (Susvimo®) |
08/6/26 |
09/6/26 |
| DMP0826-16 |
Reslizumab (Cinqair®) |
08/6/26 |
09/6/26 |
| DMP0826-17 |
Risankizumab-rzaa (Skyrizi®) |
08/6/26 |
09/6/26 |
| DMP0826-18 |
Sebelipase Alfa (Kanuma®) |
08/6/26 |
09/6/26 |
| DMP0826-19 |
Triptorelin (Triptodur®) |
08/6/26 |
09/6/26 |
| DMP0826-20 |
Triptorelin Pamoate (Trelstar®) |
08/6/26 |
09/6/26 |
| DMP0826-21 |
Vedolizumab (Entyvio®) |
08/6/26 |
09/6/26 |
| DMP0826-22 |
Alglucosidase Alfa (Lumizyme®) |
08/6/26 |
09/6/26 |
| DMP0826-23 |
Agalsidase Beta (Fabrazyme®) |
08/6/26 |
09/6/26 |
| DMP0826-24 |
Amivantamab-vmjw (Rybrevant™) |
08/6/26 |
09/6/26 |
| DMP0826-25 |
Amivantamab and Hyaluronidase-lpuj (Rybrevant Faspro™) |
08/6/26 |
09/6/26 |
| DMP0826-26 |
Depemokimab-ulaa (Exdensur) |
08/6/26 |
09/6/26 |
| DMP0826-27 |
Faricimab-svoa (Vabysmo™) |
08/6/26 |
09/6/26 |
| DMP0826-28 |
Goserelin Acetate (Zoladex®) |
08/6/26 |
09/6/26 |
| DMP0826-29 |
Histrelin Acetate (Supprelin® LA) |
08/6/26 |
09/6/26 |
| DMP0826-30 |
Leuprolide Acetate Depot Suspension [Lupron Depot (1 month) 7.5mg, Lupron Depot (3 month) 22.5mg, Lupron Depot (4-Month) 30 mg, Lupron Depot (6-Month) 45 mg]; Leuprolide acetate depot (3-month 22.5 mg); Lutrate Depot® (3-month 22.5 mg) |
08/6/26 |
09/6/26 |
| DMP0826-31 |
Leuprolide Acetate Depot Suspension (Lupron Depot-Ped®) |
08/6/26 |
09/6/26 |
| DMP0826-32 |
Leuprolide Mesylate (Camcevi ETM™; Camcevi Kit) |
08/6/26 |
09/6/26 |
| DMP0826-33 |
Mepolizumab (Nucala®) |
08/6/26 |
09/6/26 |
| DMP0826-34 |
Nusinersen (Spinraza™) |
08/6/26 |
09/6/26 |
| DMP0826-35 |
Atidarsagene Autotemcel (LENMELDY™) |
08/10/26 |
09/10/26 |
| DMP0826-36 |
Omalizumab Products: Omalizumab (Xolair®); Omalizumab-igec (Omlyclo®) |
08/10/26 |
09/10/26 |
| DMP0826-37 |
Pegunigalsidase Alfa-iwxj (Elfabrio®) |
08/10/26 |
09/10/26 |
| DMP0826-38 |
Tarlatamab-dlle (Imdelltra™) |
08/10/26 |
09/10/26 |
| DMP0826-39 |
Telisotuzumab vedotin-tllv (Emrelis™) |
08/10/26 |
09/10/26 |
| DMP0826-40 |
Testosterone Product: (Testosterone Pellets [Testopel®]) |
08/10/26 |
09/10/26 |
| DMP0826-41 |
Tezepelumab-ekko (Tezspire®) |
08/10/26 |
09/10/26 |
| DMP0826-42 |
Toripalimab-tpzi (Loqtorzi) |
08/10/26 |
09/10/26 |
| DMP0826-43 |
Ustekinumab Products: Ustekinumab (Stelara®); Ustekinumab-auub (Wezlana™); Ustekinumab-srlf (Imuldosa™); Ustekinumab-aauz (Otulfi™); Ustenkinumab-ttwe (Pyzchiva™), Ustekinumab-aekn (Selarsdi™); Ustenkinumab-stba (Steqeyma™); Ustenkinumba-kfce (Yesintek™); ustekinumab; ustekinumab-aauz, ustekinumab-stba, ustekinumab-aekn ; ustekinumab-auub; ustenkinumabttwe, Ustekinumab-hmny (Starjemza); ustekinumab-srlf |
08/10/26 |
09/10/26 |
| DMP0826-44 |
Allogeneic Regulatory T Cell Immunotherapy with HSPC and T cells-vldq (Tregzi™) |
08/19/26 |
09/8/26 |
| ID_CHS_56782026_1026 |
Teplizumab-mzwv (Tzield™) |
08/27/26 |
10/13/26 |
| ID_CHS_24132026a_0926 |
Benralizumab (Fasenra®) |
08/27/26 |
10/13/26 |
| ID_CHS_17002025_1026 |
Brentuximab Vedotin (Adcetris®) |
08/27/26 |
10/13/26 |
| ID_CHS_20042026_1026 |
Vedolizumab (Entyvio®) |
08/27/26 |
10/13/26 |
| ID_CHS_19762026a_1026 |
Ranibizumab (Lucentis®); Ranibizumab-nuna [Byooviz™]; Ranibizumab-eqrn [Cimerli™]; Ranibizumab-leyk [Nufymco™]; Ranibizumab-hkdz [Ranluspec®] |
08/27/26 |
10/13/26 |
| ID_CHS_20242026_1026 |
Aflibercept Products (Eylea®; Eylea®HD, Ahzantive™ [aflibercept-mrbb], Enzeevu™ [Aflibercept-abzv], Eydenzelt® [Aflibercept-boav], Opuviz™ [Aflibercept-yszy], Pavblu™ [Aflibercept-ayyh], and Yesafili™ [Aflibercept-jbvf]) |
08/27/26 |
10/13/26 |
| ID_CHS_18202026c_1026 |
Durvalumab (Imfinzi®) |
08/27/26 |
10/13/26 |
| ID_CHS_18942026b_1026 |
Nivolumab (Opdivo®) |
09/04/26 |
10/13/26 |
| ID_CHS_17962026a_1026 |
Ipilimumab (Yervoy®) |
08/27/26 |
10/13/26 |
| ID_CHS_67952026a_1026 |
Nivolumab and Hyaluronidase-nvhy (Opdivo Qvantig™) |
08/27/26 |
10/13/26 |
| ID_CHS_75422026_1026 |
Gedatolisib (Revtorpyk™) |
08/27/26 |
10/13/26 |
| ID_CHS_17662026_1026 |
Atezolizumab (Tecentriq®) |
09/04/26 |
10/13/26 |
| ID_CHS_66652026_1026 |
Atezolizumab and Hyaluronidase-tqjs (Tecentriq Hybreza™) |
09/04/26 |
10/13/26 |
| ID_CHS_62902025a_1026 |
Exagamglogene Autotemcel (Casgevy™) |
09/04/26 |
10/13/26 |
| ID_CHS_71362025_1026 |
Multiple Sclerosis Products:(Ocrelizumab [Ocrevus™], Ocrelizumab and Hyaluronidase-ocsq [Ocrevus Zunovo™], Ublituximab-xiiy [Briumvi™]) |
09/04/26 |
10/13/26 |
| ID_CHS_19312025b_1026 |
Pegfilgrastim (Neulasta®); Pegfilgrastim-unne ( Armlupeg® ); Pegfilgrastim-pccg (Ennumo™); Pegfilgrastim-jmdb (Fulphila®); Pegfilgrastim-pbbk (Fylnetra®); Pegfilgrastim-apgf (Nyvepria™); Pegfilgrastim-fpgk (Stimufend®); Pegfilgrastim-cbqv (Udenyca®); Pegfilgrastim-bmez (Ziextenzo™) |
09/04/26 |
10/13/26 |
| ID_CHS_71972026a_1026 |
Pembrolizumab and Berahyaluronidase alfa-pmph (Keytruda Qlex™) |
09/04/26 |
10/13/26 |
| ID_CHS_19002025_1026 |
Pemetrexed (Alimta®; Pemfexy™, Pemetrexed™, Pemrydi RTU, Axtle™) |
09/04/26 |
10/13/26 |
| ID_CHS_18992026a_1026 |
Pertuzumab (Perjeta®); Pertuzumab-dpzb (Poherdy®) |
09/04/26 |
10/13/26 |
| ID_CHS_17042025_1026 |
Rituximab Oncology Products (Rituxan®, Rituximab-abbs [Truxima®], Rituximab-arrx [Riabni™] and Rituximab-pvvr [Ruxience®]) |
09/04/26 |
10/13/26 |
| ID_CHS_19592026a_1026 |
Tocilizumab (Actemra®); Tocilizumab-anoh (Avtozma®); Tocilizumab-bavi (Tofidence™); Tocilizumab-aazg (Tyenne®), tocilizumab-aazg, tocilizumab-anoh |
09/04/26 |
10/13/26 |
| ID_CHS_20102026_1026 |
Ustekinumab Products: Ustekinumab (Stelara®); Ustekinumab-auub (Wezlana™); Ustekinumab-srlf (Imuldosa™); Ustekinumab-aauz (Otulfi™); Ustenkinumab-ttwe (Pyzchiva™), Ustekinumab-aekn (Selarsdi™); Ustenkinumab-stba (Steqeyma™); Ustenkinumba-kfce (Yesintek™); ustekinumab; ustekinumab-aauz, ustekinumab-stba, ustekinumab-aekn ; ustekinumab-auub; ustenkinumab-ttwe, Ustekinumab-hmny (Starjemza) |
09/04/26 |
10/13/26 |
| ID_CHS_51022026a_1026 |
Efgartigimod Alfa-fcab (Vyvgart®); Efgartigimod Alfa-fcab and Hyaluronidase-qvfc (Vyvgart®Hytrulo) |
09/04/26 |
10/13/26 |
| ID_CHS_36432025a_1026 |
Isatuximab-irfc (Sarclisa®; Sarclisa EscenaTM) |
09/04/26 |
10/13/26 |
| ID_CHS_73342026_1026 |
Etuvetidigene autotemcel (Waskyra®) |
09/04/26 |
10/13/26 |
