Medical and Pharmacy Coverage Policies

Effective Date	Policy Name	Reviewed Date
11/26/2025	Jascayd® (nerandomilast)	2/18/2026
4/26/2023	Jaypirca (pirtobrutinib)	4/15/2026
7/15/2020	Jelmyto (mitomycin)	11/19/2025
1/1/2026	Jelmyto (mitomycin)	11/19/2025
1/1/2026	Jelmyto (mitomycin)	11/19/2025
8/1/2021	Jemperli (dostarlimab-gxly)	9/17/2025
11/1/2025	Jemperli (dostarlimab-gxly)	9/17/2025
11/1/2025	Jemperli (dostarlimab-gxly)	9/17/2025
1/1/2020	Jevtana® (cabazitaxel)	7/15/2026
9/1/2025	Jevtana® (cabazitaxel)	7/15/2026
9/1/2025	Jevtana® (cabazitaxel)	7/15/2026
9/27/2023	Joenja® (leniolisib)	5/20/2026
4/23/2025	Journavx® (suzetrigine)	2/18/2026
1/1/2026	Juxtapid® (lomitapide)	7/15/2026
6/26/2024	Jylamvo® (methotrexate) oral solution	12/10/2025
1/1/2023	Jynarque® (tolvaptan)	2/18/2026

Pharmacy Coverage Policies