For CAPS: Added required diagnostic confirmation by either genetic testing or presence of elevated inflammatory markers plus at least two CAP-typical symptoms. For TRAPS: Added required diagnostic confirmation by genetic testing; Added required presence of chronic or recurrent disease (>6 flares per year) and submission of baseline CRP levels. For HIDS and MKD: Combined criteria into one section; Added required diagnostic confirmation by either genetic testing or presence of significantly elevated serum IgD levels; Added required history of at least 3 febrile episodes within a 6-month period and submission of baseline CRP levels. For FMF: Added required diagnostic confirmation by genetic testing; Added required presence of active disease (1 febrile episode per month) and submission of baseline CRP levels. For SJIA and AOSD: Added allowance for patients currently established on a biologic or systemic immunomodulator agent that is FDA approved for treatment of the requested indication for those who have had positive clinical benefit from use of the biologic or systemic immunomodulator agent; Added defined trial duration for conventional agents (corticosteroids and methotrexate) for AOSD to align with SJIA requirements. Added age requirement for all indications where not already present. Added examples of clinical benefit within continuation criteria. Other minor formatting changes made throughout policy for clarity with no change to intent. Policy notification given 5/1/2026 for effective date 7/1/2026.

For RA, PsA, PS, CD, AS, nr-axSpA, and PJIA: Added allowance for patients currently established on a biologic or systemic immunomodulator agent that is FDA approved for treatment of the requested indication for those who have had positive clinical benefit from use of the biologic or systemic immunomodulator agent. For PS: Adjusted phototherapy conventional agent option to include both PUVA and UVB as examples. For PsA and PS: Added additional examples defining long-term damage interfering with function associated with severe psoriatic arthritis. For CD: Removed required trial and failure of conventional therapy; Replaced allowance for severely active disease with required demonstration of moderately to severely active disease by documented presence of symptoms of active disease plus evidence of active inflammation OR significant extent of disease or upper GI involvement on radiographic or endoscopic assessment OR corticosteroid-dependence or refractory to oral corticosteroids; Changes made to align with updated clinical guidelines. Other minor formatting changes made throughout policy for clarity with no change to intent. Policy notification given 5/1/2026 for effective date 7/1/2026.

Added Site of Care medical necessity criteria for the following products: Camcevi, Camcevi ETM, Eligard, Vabrinty, Leuprolide Depot Kit, Lutrate Depot, Lupron Depot Kit, and Lupron Depot-Ped Kit. Added maximum units within dosing table specific to off-label indications (e.g., breast cancer) for applicable products. Adjusted criteria for off-label indications to remove any products without sufficient clinical evidence to support treatment of the associated off-label use. Policy notification given 5/1/2026 for effective date 7/1/2026.

For PS, PsA, CD, and UC: Added allowance for patients currently established on a biologic or systemic immunomodulator agent that is FDA approved for treatment of the requested indication for those who have had positive clinical benefit from use of the biologic or systemic immunomodulator agent. For PS: Adjusted phototherapy conventional agent option to include both PUVA and UVB as examples. For PsA and PS: Added additional examples defining long-term damage interfering with function associated with severe psoriatic arthritis. For CD: Removed required trial and failure of conventional therapy; Replaced allowance for severely active disease with required demonstration of moderately to severely active disease by documented presence of symptoms of active disease plus evidence of active inflammation OR significant extent of disease or upper GI involvement on radiographic or endoscopic assessment OR corticosteroid-dependence or refractory to oral corticosteroids; Changes made to align with updated clinical guidelines. For UC: Removed required trial and failure of conventional therapy; Replaced allowance for severely active disease with required demonstration of moderately to severely active disease by documented presence of symptoms of active disease plus evidence of active inflammation or high-risk disease (with associated confirmatory criteria) OR corticosteroid-dependence or refractory to oral corticosteroids; Changes made to align with updated clinical guidelines. Other minor formatting changes made throughout policy for clarity with no change to intent. Policy notification given 5/1/2026 for effective date 7/1/2026.

For RA, PS, PsA, AS, CD, and UC: Added allowance for patients currently established on a biologic or systemic immunomodulator agent that is FDA approved for treatment of the requested indication for those who have had positive clinical benefit from use of the biologic or systemic immunomodulator agent. For PS: Adjusted phototherapy conventional agent option to include both PUVA and UVB as examples. For PsA and PS: Added additional examples defining long-term damage interfering with function associated with severe psoriatic arthritis. For CD: Removed required trial and failure of conventional therapy; Replaced allowance for severely active disease with required demonstration of moderately to severely active disease by documented presence of symptoms of active disease plus evidence of active inflammation OR significant extent of disease or upper GI involvement on radiographic or endoscopic assessment OR corticosteroid-dependence or refractory to oral corticosteroids; Changes made to align with updated clinical guidelines. For UC: Removed required trial and failure of conventional therapy; Replaced allowance for severely active disease with required demonstration of moderately to severely active disease by documented presence of symptoms of active disease plus evidence of active inflammation or high-risk disease (with associated confirmatory criteria) OR corticosteroid-dependence or refractory to oral corticosteroids; Changes made to align with updated clinical guidelines. Other minor formatting changes made throughout policy for clarity with no change to intent. Policy notification given 5/1/2026 for effective date 7/1/2026.

Added requirement for trial and failure of Cinqair prior to use of Exdensur within initial and continuation criteria (requiring trial and failure of Cinqair AND Fasenra and Nucala [both provider-administered and self-administered]). For EGPA indication: Removed required trial and failure of an oral immunosuppressant. Added diagnostic requirement of documented baseline eosinophil count ≥1000 cells/microliter or level ≥10%. Added requirements of no presence of severe disease and for use as treatment for either relapsing/refractory disease or maintenance of disease remission. For EGPA continuation criteria, added requirement for documented improvement or stabilization with treatment. For CRSwNP indication: Added diagnostic requirements of presence of at least 2 inadequately controlled symptoms for at least 12 consecutive weeks prior to therapy initiation, and documented diagnostic confirmation by either anterior rhinoscopy, nasal endoscopy, or sinus CT imaging. Listed examples of nasal polyp surgery for clarity. Removed required trial and failure of Xhance or oral systemic corticosteroids, and updated trial and failure requirements to instead include an intranasal corticosteroid for at least 4 consecutive weeks within 12 weeks prior to therapy initiation. Removed requirement of no combination use with Xhance. For CRSwNP continuation criteria, added requirement for documented demonstration of positive clinical response. Adjusted verbiage for current treatment with an intranasal corticosteroid within initial and continuation sections to add that the patient will continue to be treated with the intranasal corticosteroid. For HES indication: Added required medical record documentation for eosinophil count. For asthma indication: Reformatted description of exacerbation history demonstrating uncontrolled disease despite adherence to asthma control therapy for clarity with no change to intent. Removed requirement for no presence of neoplastic disease or known/suspected parasitic infection. For COPD indication: Reformatted description of exacerbation history demonstrating uncontrolled disease despite adherence to COPD inhaled maintenance therapy for clarity with no change to intent. Adjusted list of biologic immunomodulator agents not to be used in combination for clarity. Other minor adjustments made throughout policy for clarity with no change to policy intent. References added. Policy notification given 5/1/2026 for effective date 7/1/2026.

For CD: Removed required trial and failure of conventional therapy; Replaced allowance for severely active disease with required demonstration of moderately to severely active disease by documented presence of symptoms of active disease plus evidence of active inflammation OR significant extent of disease or upper GI involvement on radiographic or endoscopic assessment OR corticosteroid-dependence or refractory to oral corticosteroids; Changes made to align with updated clinical guidelines. For UC: Removed required trial and failure of conventional therapy; Replaced allowance for severely active disease with required demonstration of moderately to severely active disease by documented presence of symptoms of active disease plus evidence of active inflammation or high-risk disease (with associated confirmatory criteria) OR corticosteroid-dependence or refractory to oral corticosteroids; Changes made to align with updated clinical guidelines. For CD and UC: Added allowance for patients currently established on a biologic or systemic immunomodulator agent that is NOT the requested agent and is FDA approved for treatment of the requested indication for those who have had positive clinical benefit from use of the biologic or systemic immunomodulator agent. Other minor formatting changes made throughout policy for clarity with no change to intent. Policy notification given 5/1/2026 for effective date 7/1/2026.

For CD: Added allowance for patients currently established on a biologic or systemic immunomodulator agent that is FDA approved for treatment of the requested indication for those who have had positive clinical benefit from use of the biologic or systemic immunomodulator agent; Removed required trial and failure of conventional therapy; Replaced allowance for severely active disease with required demonstration of moderately to severely active disease by documented presence of symptoms of active disease plus evidence of active inflammation OR significant extent of disease or upper GI involvement on radiographic or endoscopic assessment OR corticosteroid-dependence or refractory to oral corticosteroids; Changes made to align with updated clinical guidelines. Other minor formatting changes made throughout policy for clarity with no change to intent. Policy notification given 5/1/2026 for effective date 7/1/2026.

For CRSwNP indication: Added diagnostic requirements of presence of at least 2 inadequately controlled symptoms for at least 12 consecutive weeks prior to therapy initiation, and documented diagnostic confirmation by either anterior rhinoscopy, nasal endoscopy, or sinus CT imaging. Listed examples of nasal polyp surgery for clarity. Removed required trial and failure of Xhance or oral systemic corticosteroids, and updated trial and failure requirements to instead include an intranasal corticosteroid for at least 4 consecutive weeks within 12 weeks prior to therapy initiation. Removed requirement of no combination use with Xhance. For CRSwNP continuation criteria, added requirement for documented demonstration of positive clinical response. Adjusted verbiage for current treatment with an intranasal corticosteroid within initial and continuation sections to add that the patient will continue to be treated with the intranasal corticosteroid. For asthma indication: Reformatted description of exacerbation history demonstrating uncontrolled disease despite adherence to asthma control therapy for clarity with no change to intent. Adjusted list of biologic immunomodulator agents not to be used in combination for clarity. Other minor adjustments made throughout policy for clarity with no change to policy intent. References added. Policy notification given 5/1/2026 for effective date 7/1/2026.

For CD: Removed required trial and failure of conventional therapy; Replaced allowance for severely active disease with required demonstration of moderately to severely active disease by documented presence of symptoms of active disease plus evidence of active inflammation OR significant extent of disease or upper GI involvement on radiographic or endoscopic assessment OR corticosteroid-dependence or refractory to oral corticosteroids; Changes made to align with updated clinical guidelines. For UC: Removed required trial and failure of conventional therapy; Replaced allowance for severely active disease with required demonstration of moderately to severely active disease by documented presence of symptoms of active disease plus evidence of active inflammation or high-risk disease (with associated confirmatory criteria) OR corticosteroid-dependence or refractory to oral corticosteroids; Changes made to align with updated clinical guidelines. For CD and UC: Added allowance for patients currently established on a biologic or systemic immunomodulator agent that is NOT the requested agent and is FDA approved for treatment of the requested indication for those who have had positive clinical benefit from use of the biologic or systemic immunomodulator agent. Other minor formatting changes made throughout policy for clarity with no change to intent. Policy notification given 5/1/2026 for effective date 7/1/2026.

For CRSwNP indication: Added diagnostic requirements of presence of at least 2 inadequately controlled symptoms for at least 12 consecutive weeks prior to therapy initiation, and documented diagnostic confirmation by either anterior rhinoscopy, nasal endoscopy, or sinus CT imaging. Removed required trial and failure of Xhance or oral systemic corticosteroids, and updated trial and failure requirements to only include an intranasal corticosteroid for at least 4 consecutive weeks within 12 weeks prior to therapy initiation. Removed requirement of no combination use with Xhance. For CRSwNP continuation criteria, added requirement for documented demonstration of positive clinical response. Adjusted verbiage for current treatment with an intranasal corticosteroid within initial and continuation sections to add that the patient will continue to be treated with the intranasal corticosteroid. For asthma indication: Reformatted description of exacerbation history demonstrating uncontrolled disease despite adherence to asthma control therapy for clarity with no change to intent. Adjusted list of biologic immunomodulator agents not to be used in combination for clarity. Other minor adjustments made throughout policy for clarity with no change to policy intent. References added. Policy notification given 5/1/2026 for effective date 7/1/2026.

For CRS: Adjusted criteria to allow for proactive prescribing of tocilizumab in anticipation of possible CRS with documented confirmation of planned or current treatment with CAR-T therapy; Changed maximum units to reflect a maximum of four 800 mg doses, and extended duration of approval to 180 days (maximum of 4 doses) to align with CAR-T authorization timeframe. For RA, GCA, PJIA, SJIA, and SSc-ILD: Added allowance for patients currently established on a biologic or systemic immunomodulator agent that is FDA approved for treatment of the requested indication for those who have had positive clinical benefit from use of the biologic or systemic immunomodulator agent. Other minor formatting changes made throughout policy for clarity with no change to intent. Policy notification given 5/1/2026 for effective date 7/1/2026.

For PS, PsA, CD, and UC: Added allowance for patients currently established on a biologic or systemic immunomodulator agent that is FDA approved for treatment of the requested indication for those who have had positive clinical benefit from use of the biologic or systemic immunomodulator agent. For PS: Adjusted phototherapy conventional agent option to include both PUVA and UVB as examples. For PsA and PS: Added additional examples defining long-term damage interfering with function associated with severe psoriatic arthritis. For CD: Removed required trial and failure of conventional therapy; Replaced allowance for severely active disease with required demonstration of moderately to severely active disease by documented presence of symptoms of active disease plus evidence of active inflammation OR significant extent of disease or upper GI involvement on radiographic or endoscopic assessment OR corticosteroid-dependence or refractory to oral corticosteroids; Changes made to align with updated clinical guidelines. For UC: Removed required trial and failure of conventional therapy; Replaced allowance for severely active disease with required demonstration of moderately to severely active disease by documented presence of symptoms of active disease plus evidence of active inflammation or high-risk disease (with associated confirmatory criteria) OR corticosteroid-dependence or refractory to oral corticosteroids; Changes made to align with updated clinical guidelines. Other minor formatting changes made throughout policy for clarity with no change to intent. Policy notification given 5/1/2026 for effective date 7/1/2026.

For CD and UC: Added allowance for patients currently established on a biologic or systemic immunomodulator agent that is FDA approved for treatment of the requested indication for those who have had positive clinical benefit from use of the biologic or systemic immunomodulator agent. For CD: Removed required trial and failure of conventional therapy; Replaced allowance for severely active disease with required demonstration of moderately to severely active disease by documented presence of symptoms of active disease plus evidence of active inflammation OR significant extent of disease or upper GI involvement on radiographic or endoscopic assessment OR corticosteroid-dependence or refractory to oral corticosteroids; Changes made to align with updated clinical guidelines. For UC: Removed required trial and failure of conventional therapy; Replaced allowance for severely active disease with required demonstration of moderately to severely active disease by documented presence of symptoms of active disease plus evidence of active inflammation or high-risk disease (with associated confirmatory criteria) OR corticosteroid-dependence or refractory to oral corticosteroids; Changes made to align with updated clinical guidelines. Other minor formatting changes made throughout policy for clarity with no change to intent. Policy notification given 5/1/2026 for effective date 7/1/2026.

Added Site of Care medical necessity criteria for the following products: Armlupeg, Filkri, Granix, Neulasta, Neulasta OnPro, Neupogen, Nypozi, Nyvepria, Releuko, Rolvedon, Ryzneuta, Stimufend, Udenyca, Udenyca Onbody, and Ziextenzo. Policy notification given 5/1/2026 for effective date 7/1/2026.