Medical and Pharmacy Coverage Policies

Effective Date	Policy Name	Reviewed Date
6/28/2023	Qalsody™ (tofersen)	3/18/2026
6/1/2026	Qalsody™ (tofersen)	3/18/2026
7/23/2025	Qbrexza® (glycopyrronium) Cloth	7/15/2026
1/1/2026	Qelbree® (viloxazine)	3/18/2026
6/25/2025	Qfitlia™ (fitusiran) subcutaneous injection	2/18/2026
1/1/2026	Qinlock (ripretinib)	3/18/2026
1/1/2025	Qualaquin® (quinine sulfate)	8/19/2026
1/1/2017	Quantity Limitation	6/25/2026
7/1/2026	Quantity Limitation	6/25/2026
1/1/2026	Qudexy XR®, Trokendi XR® (topiramate)	5/20/2026
1/1/2025	Qulipta (atogepant)	7/15/2026
1/1/2026	Qutenza® (capsaicin) 8% patch	4/15/2026
1/1/2024	Quviviq (daridorexant)	12/10/2025

Pharmacy Coverage Policies