Medical and Pharmacy Coverage Policies

Effective Date	Policy Name	Reviewed Date
1/1/2024	Ubrelvy™ (ubrogepant)	1/21/2026
1/1/2022	Uceris® Tablet and Rectal Foam (budesonide)	12/10/2025
1/1/2025	Ulcerative Colitis Agents	11/19/2025
3/5/2009	Uloric® (febuxostat)	1/21/2026
1/1/2025	Ultomiris® (ravulizumab-cwvz)	5/20/2026
8/1/2026	Ultomiris® (ravulizumab-cwvz)	5/20/2026
9/3/2015	Unituxin (dinutuximab)	6/17/2026
1/1/2026	Unituxin (dinutuximab)	6/17/2026
2/25/2026	Unloxcyt™ (cosibelimab-ipdl)	2/18/2026
5/1/2026	Unloxcyt™ (cosibelimab-ipdl)	2/18/2026
5/1/2026	Unloxcyt™ (cosibelimab-ipdl)	2/18/2026
1/1/2022	Uplizna® (inebilizumab-cdon)	3/18/2026
6/1/2026	Uplizna® (inebilizumab-cdon)	3/18/2026
1/1/2026	Uptravi® (selexipag)	5/20/2026
3/17/2021	Ursodiol Products	8/19/2026

Pharmacy Coverage Policies