| Medical Mutual | Prior approval is required for some or all procedure codes listed in this Corporate Drug Policy. | 2025-04-17 |
| Medical Mutual | Nulibry™ (fosdenopterin) | 2025-04-17 |
| Medical Mutual | Ocrevus ® (ocrelizumab) | 2025-04-17 |
| Medical Mutual | Revcovi™ (elapegademase-lvlr injection for | 2025-04-17 |
| Medical Mutual | Trisenox® (arsenic trioxide) | 2025-04-17 |
| Medical Mutual | Xolair® (omalizumab injection for subcutaneous | 2025-04-17 |
| Anthem Blue Cross | Treatment of Varicose Veins (Lower Extremities) | 2025-04-16 |
| Anthem Blue Cross | Renal Sympathetic Nerve Ablation | 2025-04-16 |
| Anthem Blue Cross | Presbyopia and Astigmatism-Correcting Intraocular Lenses | 2025-04-16 |
| Aetna | Chronic Pain Programs | 2025-04-16 |