Medical and Pharmacy Coverage Policies

Effective Date	Policy Name	Reviewed Date
9/26/2018	Galafold®(migalastat)	12/10/2025
11/1/2025	Gamifant® (emapalumab-lzsg)	6/17/2026
11/1/2025	Gamifant® (emapalumab-lzsg)	6/17/2026
4/23/2019	Gamifant® (emapalumab-lzsg)	6/17/2026
1/1/2019	Gattex® (teduglutide)	7/15/2026
11/11/2020	Gavreto (pralsetinib)	3/18/2026
1/1/2020	Gazyva® (obinutuzumab)	12/10/2025
2/1/2026	Gazyva® (obinutuzumab)	12/10/2025
2/1/2026	Gazyva® (obinutuzumab)	12/10/2025
1/1/2020	Gilotrif (afatinib)	10/15/2025
1/20/2021	Gimoti (metoclopramide)	7/15/2026
3/18/2020	Givlaari® (givosiran)	7/15/2026
10/1/2025	Givlaari® (givosiran)	8/20/2025
10/1/2025	Givlaari® (givosiran)	8/19/2026
10/1/2025	Givlaari® (givosiran)	8/19/2026
1/1/2020	Gleostine (lomustine)	12/10/2025
1/1/2019	GLP-1 Analogs	3/20/2024
1/1/2026	Glucagon Products	6/17/2026
1/1/2026	GnRH Receptor Antagonists (Myfembree®, Oriahnn®)	5/21/2025
1/1/2026	GnRH Receptor Antagonists (Myfembree®, Oriahnn®)	4/15/2026
1/1/2026	GnRH Receptor Antagonists (Myfembree®, Oriahnn®)	6/17/2026
1/1/2022	Gocovri® (amantadine extended release)	11/19/2025
5/28/2025	Gomekli (mirdametinib)	1/21/2026
1/1/2020	Gralise® (gabapentin)	10/15/2025
1/1/2026	Granix® (tbo-filgrastim)	1/21/2026
1/1/2026	Granix® (tbo-filgrastim)	1/21/2026
1/1/2021	Growth Hormone	7/15/2026

Pharmacy Coverage Policies