Medical and Pharmacy Coverage Policies Home

Pharmacy Coverage Policies

Search Results

Effective DatePolicy NameReviewed Date
8/23/2023 LAMZEDE® (velmanase alfa-tycv)
4/15/2026
7/1/2024 LAMZEDE® (velmanase alfa-tycv)
5/21/2025
1/1/2026 LAMZEDE® (velmanase alfa-tycv)
8/20/2025
1/1/2025 Lanreotide Products
2/18/2026
1/28/2026 Lasix® ONYU (furosemide)
1/21/2026
10/23/2024 Lazcluze (lazertinib)
1/21/2026
1/1/2021 Lemtrada® (alemtuzumab)
8/19/2026
1/1/2026 Lenvima (lenvatinib)
4/15/2026
8/23/2023 Leqembi® (lecanemab-irmb)
10/15/2025
1/1/2026 Leqembi-Iqlik (lecanemab-irmb) subcutaneous auto-injector
8/19/2026
5/27/2026 Leqselvi™ (deuruxolitinib)
5/20/2026
1/1/2026 Leqvio® (inclisiran)
8/19/2026
1/1/2026 Leqvio® (inclisiran)
4/15/2026
4/22/2026 Lerochol™ (lerodalcibep-liga)
4/15/2026
1/1/2021 Letairis® (ambrisentan)
10/15/2025
1/1/2026 Leukine® (sargramostim/GM-CSF)
1/21/2026
1/1/2026 Leuprolide Acetate (Lupron, Lutrate) and Generic Depot Products
4/15/2026
1/1/2026 Leuprolide Acetate Subcutaneous Products (Eligard and Vabrinty)
4/15/2026
4/17/2019 Levoleucovorin products
8/19/2026
1/1/2023 Levoleucovorin products
8/19/2026
7/1/2024 Levoleucovorin products
8/19/2026
9/24/2025 Levoleucovorin products
8/19/2026
1/1/2026 Levorphanol tablets
3/18/2026
1/1/2026 Levothyroxine Oral Solution
5/20/2026
1/1/2026 L-glutamine (Endari) oral powder packet
3/18/2026
12/12/2018 Libtayo® (cemiplimab-rwlc)
12/10/2025
2/1/2026 Libtayo® (cemiplimab-rwlc)
12/10/2025
2/1/2026 Libtayo® (cemiplimab-rwlc)
12/10/2025
1/1/2026 Lidocaine 5% topical ointment
5/20/2026
1/1/2020 Lidocaine 5% topical patch
11/19/2025
1/1/2026 Lidocaine Patch 5% (Lidoderm®, DermacinRx Lidocan™, Lidocan™ II-V)
5/20/2026
1/1/2022 Lifetime Dosing Limits
9/17/2025
5/27/2026 Lifyorli (relacorilant)
7/15/2026
1/1/2019 Limited Day Supply
12/23/2025
10/1/2025 Limited Day Supply
8/28/2025
10/1/2025 Limited Day Supply
4/16/2026
1/1/2023 Liposomal doxorubicin
5/20/2026
10/22/2025 Liposomal doxorubicin
10/15/2025
12/1/2025 Liposomal doxorubicin
5/20/2026
12/1/2025 Liposomal doxorubicin
5/20/2026
10/22/2025 Liposomal doxorubicin
5/20/2026
1/1/2021 Lisdexamfetamine Products
4/15/2026
9/27/2023 Litfulo™ (ritlecitinib)
7/15/2026
1/1/2022 Livalo® (pitavastatin)
2/18/2026
11/27/2024 Livdelzi® capsule
11/19/2025
12/15/2021 Livmarli® (maralixibat)
12/10/2025
1/19/2022 Livtencity (maribavir) tablet
3/18/2026
4/22/2026 Loargys® (pegzilarginase-nbln) injection solution
4/15/2026
7/1/2026 Loargys® (pegzilarginase-nbln) injection solution
4/15/2026
12/20/2023 Lodoco® (colchicine)
11/19/2025
1/1/2026 Lofexidine (Lucemyra) tablet
3/18/2026
1/1/2024 Long Acting Beta Agonists
4/15/2026
1/1/2026 Long Acting Insulins
4/15/2026
1/1/2025 Long Acting Muscarinic Antagonist / Long Acting Beta Agonist Combo Inhalers
5/20/2026
1/1/2026 Long Acting Opioids
3/18/2026
1/1/2020 Lonsurf® (trifluridine and tipiracil)
12/10/2025
2/28/2024 Loqtorzi™ (toripalimab-tpzi)
12/10/2025
2/1/2026 Loqtorzi™ (toripalimab-tpzi)
12/10/2025
2/1/2026 Loqtorzi™ (toripalimab-tpzi)
12/10/2025
1/1/2026 Lorbrena (lorlatinib)
2/18/2026
9/22/2021 Loreev XR® (lorazepam)
2/18/2026
1/1/2025 Lotronex (alosetron)
5/20/2026
1/1/2024 Lucentis® (ranibizumab)
1/21/2026
1/1/2025 Lucentis® (ranibizumab)
1/21/2026
10/1/2025 Lucentis® (ranibizumab)
9/17/2025
10/1/2025 Lucentis® (ranibizumab)
1/21/2026
7/1/2024 Lucentis® (ranibizumab)
1/21/2026
1/1/2026 Lumakras (sotorasib)
2/18/2026
1/1/2011 Lumizyme® (alglucosidase alpha)
7/15/2026
7/26/2023 Lumryz (sodium oxybate)
7/17/2024
1/1/2025 Lumryz (sodium oxybate)
2/18/2026
3/22/2023 Lunsumio® & Lunsumio Velo™ (mosunetuzumab-axgb)
2/18/2026
5/1/2026 Lunsumio® & Lunsumio Velo™ (mosunetuzumab-axgb)
2/18/2026
5/1/2026 Lunsumio® & Lunsumio Velo™ (mosunetuzumab-axgb)
2/18/2026
5/19/2021 Lupkynis® (voclosporin)
2/18/2026
1/1/2020 Lutathera (lutetium Lu 177 dotatate)
8/19/2026
11/1/2025 Lutathera (lutetium Lu 177 dotatate)
8/19/2026
1/1/2020 Luxturna® (voretigene neparvovec-rzyl)
12/10/2025
1/19/2024 Luxturna® (voretigene neparvovec-rzyl)
12/10/2025
1/1/2025 Lybalvi® (olanzapine and samidorphan)
8/19/2026
3/25/2026 Lymphir™ (denileukin diftitox-cxdl)
3/18/2026
6/1/2026 Lymphir™ (denileukin diftitox-cxdl)
3/18/2026
6/1/2026 Lymphir™ (denileukin diftitox-cxdl)
3/18/2026
7/22/2026 Lynavoy (linerixibat)
7/15/2026
1/28/2026 Lynkuet® (elinzanetant)
1/21/2026
9/24/2025 Lynozyfic (linvoseltamab-gcpt)
7/15/2026
1/1/2026 Lynparza (olaparib)
5/20/2026
1/1/2026 Lyrica® CR (pregabalin)
4/15/2026
2/15/2023 Lytgobi (futibatinib)
5/20/2026
  • 1

Search by Keyword or Policy Number