Medical and Pharmacy Coverage Policies

Effective Date	Policy Name	Reviewed Date
1/1/2025	Haegarda (C1 esterase inhibitor, human)	1/15/2026
9/24/2025	Harliku™ (nitisinone)	8/19/2026
1/1/2026	Harvoni (ledipasvir/sofosbuvir)	6/17/2026
1/1/2025	Helicobacter Pylori Agents	5/20/2026
12/9/2020	Hemady (dexamethasone tablet)	3/18/2026
6/1/2023	Hemgenix (etranacogene dezaparvovec-drlb)	4/15/2026
1/1/2020	Hemlibra® (emicizumab-kxwh)	2/18/2026
8/26/2026	Hepcludex® (bulevirtide-gmod)	8/19/2026
9/4/2026	Herceptin Hylecta (trastuzumab and hyaluronidase oysk)	9/3/2026
3/1/2026	Herceptin Hylecta (trastuzumab and hyaluronidase- oysk)	6/17/2026
3/1/2026	Herceptin Hylecta (trastuzumab and hyaluronidase- oysk)	6/17/2026
3/1/2026	Herceptin Hylecta (trastuzumab and hyaluronidase- oysk)	6/17/2026
1/1/2023	Herceptin Hylecta (trastuzumab and hyaluronidase-oysk)	9/3/2026
10/22/2025	Hernexeos (zongertinib)	5/20/2026
1/1/2025	Hetlioz® and Hetlioz LQ™ (tasimelteon)	3/18/2026
1/1/2018	Horizant® (gabapentin enacarbil)	1/21/2026
9/28/2022	Hyftor™ (sirolimus topical gel)	8/19/2026
2/26/2025	Hympavzi Pen subcutaneous pen injector	2/18/2026
1/1/2023	Hypomethylating agents (azacitidine, decitabine)	6/17/2026
2/25/2026	Hyrnuo (sevabertinib)	2/18/2026

Pharmacy Coverage Policies