Effective March 1, 2026: Pharmacy and Biopharmacy Policies

POLICY

APPLICABLE PRODUCTS

NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS

Omalizumab (Xolair) (CP.PCH.49)

Ambetter

Policy updates include:

• Added coverage for moderate (G2) immune checkpoint inhibitor-related pruritus per National Comprehensive Cancer Network (NCCN)
• For all indications, revised initial approval duration for Ambetter from 6 to 12 months and for Commercial to include “or to the member’s renewal date, whichever is longer” and for National Comprehensive Cancer Network (NCCN) compendial uses, revised continued approval duration for Ambetter from 6 to 12 months and for Commercial to include “or to the member’s renewal date, whichever is longer”
• Added eosinophilic esophagitis as an indication not covered in section III given lack of demonstrated efficacy and recommendation against use by the 2025 American College of Gastroenterology guideline
• Added newly approved 300 mg/2 ml strength for Omlyclo

Axitinib (Inlyta) (CP.PHAR.100)

Ambetter

Policy updates include:

• For differentiated thyroid carcinoma, removed requirement for radioactive iodine therapy for oncocytic carcinoma and revised status from “not amenable” to “refractory” per National Comprehensive Cancer Network (NCCN)
• Added off-label indication of endometrial carcinoma per National Comprehensive Cancer Network (NCCN)
• Revised initial approval durations for Medicaid and Ambetter to 12 months
• Added request does not exceed health plan-approved quantity limit, if applicable

Enzalutamide (Xtandi) (CP.PHAR.106)

Ambetter

Policy updates include:

• Per National Comprehensive Cancer Network (NCCN) Compendium added off-label use in non-metastatic castration-resistant prostate cancer as secondary hormone therapy with prostate-specific antigen doubling time at most 10 months
• Added template language “Request does not exceed health plan-approved quantity limit
• Revised initial approval duration from 6 to 12 months, if applicable

Cabozantinib (Cabometyx, Cometriq) (CP.PHAR.111)

Ambetter

Policy updates include:

• For renal cell carcinoma, added combination with Opdivo Qvantig as option to Opdivo
• For hepatocellular carcinoma, removed disease qualifiers per National Comprehensive Cancer Network (NCCN)
• For differentiated thyroid carcinoma, revised drug request requirement to allow only Cabometyx, removed requirement for radioactive iodine therapy for oncocytic carcinoma, and revised radioactive iodine therapy status from “not amenable” to “refractory” per National Comprehensive Cancer Network (NCCN)
• For non-small cell lung cancer, added requirement for use as subsequent therapy per National Comprehensive Cancer Network (NCCN)
• Removed brain metastases from off-label indications as these are metastases f renal cell carcinoma
• For off-label indications, added supported bone cancer types, supported soft tissue sarcoma types, requirement for monotherapy use in soft tissue sarcoma, and disease qualifiers for gastrointestinal stromal tumor per National Comprehensive Cancer Network (NCCN)
• Revised initial approval durations for Medicaid and Ambetter to 12 months
• Added request does not exceed health plan-approved quantity limit, if applicable

Ramucirumab (Cyramza) (CP.PHAR.119)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• For hepatocellular carcinoma, revised progression on sorafenib to subsequent therapy use per National Comprehensive Cancer Network (NCCN)
• Removed appendiceal adenocarcinoma indication and added thymic carcinoma as off-label indication per National Comprehensive Cancer Network (NCCN)
• Revised approval durations for Medicaid/ Ambetter to 12 months and for Commercial line of business to “6 months or duration of request, whichever is less”

Nivolumab (Opdivo), Nivolumab/Hyaluronidase-nvhy (Opdivo Qvantig) (CP.PHAR.121)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• For melanoma, added option for resectable stage III or limited local satellite/in-transit recurrence or nodal recurrence
• For malignant pleural mesothelioma, removed requirement for unresectable
• For renal cell carcinoma, added option to be prescribed for hereditary leiomyomatosis and renal cell carcinoma-associated renal cell carcinoma
• For classic Hodgkin lymphoma: added request is for Opdivo as National Comprehensive Cancer Network (NCCN) does not included recommended use in this setting, for primary treatment, removed staging requirement (III-IV) and added option if member is not candidate for anthracycline
• Added option for use post allogenic hematopoietic cell transplant
• For relapsed/refractory/or progressive disease, added option for combo use with Adcentris or ICE (ifosfomaide, carboplatin, etoposide)
• Added off-label indications for appendiceal neoplasms and cancers, squamous cell skin cancer, and uterine sarcoma per National Comprehensive Cancer Network (NCCN)
• For bone cancer, added option for combination use with Sutent for dedifferentiated chrondrosarcoma
• For chronic lymphocytic leukemia/small lymphocytic lymphoma, removed combo use with Yervoy and added single agent or combination with Imbruvica
• For vaginal cancer, added prescribed as a single agent or in combination with Yervoy
• For pediatric Hodgkin lymphoma, removed requirement for re-induction therapy or subsequent therapy
• Extended initial approval duration from 6 to 12 months for this maintenance medication for a chronic condition
• For Opdivo Qvantig: for colorectal cancer added new indication for use that has progressed following treatment with a fluoropyrimidine, oxaliplatin, and irinotecan and converted from accelerated approval to full approval for use following combination treatment
• For hepatocellular carcinoma, added new indication for use as first-line treatment following combination treatment and converted from accelerated approval to full approval for those who have been previously treated with sorafenib and removed requirement that member is deemed ineligible for resection, transplant, or locoregional therapy
• For Opdivo Qvantig, for melanoma and colorectal cancer added pediatric extension to age at least 12 years (previously approved in adults) and new dosage strength (300 mg/5,000 units).

Ibrutinib (Imbruvica) (CP.PHAR.126)

Ambetter

Policy updates include:

• Updated criteria to align with the latest National Comprehensive Cancer Network (NCCN) guidelines: specified that coverage for post-transplant lymphoproliferative disorders is for monomorphic post-transplant lymphoproliferative disorders, removed the requirement for del(17p)/TP53 mutation in the setting of histologic transformation to diffuse large B-cell lymphoma, removed relapsed brain metastases in lymphoma
• For Waldenström’s macroglobulinemia and marginal zone lymphoma added exclusion against concomitant use with Calquence or Brukinsa to align with existing Brukinsa and Calquence criteria
• Updated initial auth durations from 6 months to 12 months for Medicaid and Ambetter

Romiplostim (Nplate) (CP.PHAR.179)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Added National Comprehensive Cancer Network (NCCN) Compendium supported off label use for immune checkpoint inhibitor-related toxicities when member has had no response to corticosteroids after 1-2 weeks

Eltrombopag (Alvaiz, Promacta) (CP.PHAR.180)

Ambetter

Policy updates include:

• For post-hematopoietic cell transplant with prolonged thrombocytopenia, added requirement that member has poor graft function per National Comprehensive Cancer Network (NCCN)
• Added National Comprehensive Cancer Network (NCCN)-supported indications of immune effector cell-associated hematologic toxicity and immunotherapy-related thrombocytopenia
• For eltrombpag and Promacta, added request does not exceed health plan-approved quantity limit, if applicable

Aflibercept (Eylea, Eylea HD), Aflibercept-yszy (Opuviz), Aflibercept-jbvf (Yesafili), Aflibercept-mrbb (Ahzantive), Aflibercept-abzv (Enzeevu), Aflibercept-ayyh (Pavblu) (CP.PHAR.184)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Combined retinal vein occlusion section with neovascular (wet) age-related macular degeneration, diabetic macular edema, and diabetic retinopathy section
• For adult ophthalmic diseases, extended continued therapy duration from 6 months to 12 months for this maintenance medication for a chronic condition
• For retinopathy of prematurity, clarified 3 lifetime doses per eye
•  For Eylea HD, added criteria for newly Food and Drug Administration (FDA)-approved indication of retinal vein occlusion
• In continued therapy, added option for every 4 week dosing if documentation supports evidence of continued disease activity.

Ranibizumab (Byooviz, Cimerli, Lucentis, Susvimo) (CP.PHAR.186)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• For diabetic macular edema, diabetic retinopathy, retinal vein occlusion, and neovascular (wet) age-related macular degeneration, extended continued therapy duration from 6 months to 12 months for this maintenance medication for a chronic condition

Verteporfin (Visudyne) (CP.PHAR.187)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Clarified one dose every 3 months

Ambrisentan (Letairis) (CP.PHAR.190)

Ambetter

Policy updates include:

• Added requirement that request does not exceed health-plan approved quantity limit
• Extended Medicaid and Ambetter initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition

Bosentan (Tracleer) (CP.PHAR.191)

Ambetter

Policy updates include:

• Added requirement that request does not exceed health-plan approved quantity limit
• Extended Medicaid and Ambetter initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition

Epoprostenol (Flolan, Veletri) (CP.PHAR.192)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Extended Medicaid and Ambetter initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition

Iloprost (Ventavis) (CP.PHAR.193)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Extended Medicaid and Ambetter initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition

Macitentan (Opsumit) (CP.PHAR.194)

Ambetter

Policy updates include:

• Added requirement that request does not exceed health-plan approved quantity limit
• Extended Medicaid and Ambetter initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition

Riociguat (Adempas) (CP.PHAR.195)

Ambetter

Policy updates include:

• Added requirement that request does not exceed health-plan approved quantity limit
• Extended Medicaid and Ambetter initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition

Selexipag (Uptravi) (CP.PHAR.196)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Clarified maximum dose for concomitant administration with CYP2C8 inducers
• Clarified requirement for titration plan is for oral Uptravi
• Added requirement that request does not exceed health-plan approved quantity limit
• Extended Medicaid and Ambetter initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition

Sildenafil (Revatio, Liqrev) (CP.PHAR.197)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Added requirement that request does not exceed health-plan approved quantity limit
• Extended Medicaid and Ambetter initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition

Tadalafil (Adcirca, Alyq, Tadliq) (CP.PHAR.198)

Ambetter

Policy updates include:

• Added requirement that request does not exceed health-plan approved quantity limit
• Extended Medicaid and Ambetter initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition

Treprostinil (Orenitram, Remodulin, Tyvaso, Tyvaso DPI) (CP.PHAR.199)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• For Orenitram, added requirement that request does not exceed health-plan approved quantity limit
• For Tyvaso and Tyvaso DPI, revised maximum dose criterion to member must submit a titration plan if member requires titration
• Extended Medicaid and Ambetter initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition

Trabectedin (Yondelis) (CP.PHAR.204)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Added the following sub-types of soft tissue sarcoma without requiring disease to be unresectable or metastatic: solitary fibrous tumor, epithelioid hemangioendothelioma, or dedifferentiated liposarcoma with or without concurrent well-differentiated liposarcoma per National Comprehensive Cancer Network (NCCN)
• For Medicaid and Ambetter extended initial approval duration from 6 to 12 months for this maintenance medication for a chronic condition

Factor VIIa, Recombinant (NovoSeven RT, SevenFact) (CP.PHAR.220)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• For “Hemophilia, Congenital Factor VII Deficiency” indication, clarified terminology from “prevention” to Food and Drug Administration (FDA)-labeled indication of “control” of bleeding episodes to prevent misinterpretation of criteria

OnabotulinumtoxinA (Botox) (CP.PHAR.232)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• For chronic migraine removed requirement for evidence from two high quality published studies to support concurrent use of Botox and calcitonin gene-related peptide (CGRP) therapy.

Atezolizumab (Tecentriq), Atezolizumab-Hyaluronidase (Tecentriq Hybreza) (CP.PHAR.235)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• For non-small cell lung cancer, revised stage from IIA to IB and modified criterion to meet all requirements, including previous resection per National Comprehensive Cancer Network (NCCN)
• For hepatocellular carcinoma, removed requirement for use as first-line therapy or as adjuvant therapy
• For cervical cancer, expanded diagnosis to cervical cancer and added option to be prescribed in combination with bevacizumab, paclitaxel, and cisplatin/carboplatin
• Added criteria for the following off-label indications: thymomas and thymic carcinomas, chronic lymphocytic leukemia/small lymphocytic lymphoma and colon cancer per National Comprehensive Cancer Network (NCCN)
• For Medicaid and Ambetter lines of business, extended initial approval duration from 6 to 12 months for this maintenance medication for a chronic condition
• For small cell lung cancer, added option for combination use with Zepzelca following combination use with carboplatin plus etoposide
• Added pediatric extension for age at least 12 years (previously only approved in adults) for alveolar soft part sarcomper prescribing information.

Siltuximab (Sylvant) (CP.PHAR.329)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Extended initial approval duration from 6 to 12 months for this maintenance medication for a chronic condition
• In cytokine release syndrome initial criteria, added Avtozma may be used to replace the second dose of Tyenne per National Comprehensive Cancer Network (NCCN)
• For off-label unicentric Castleman’s disease, revised usage from “relapsed or refractory” to “surgically unresectable/or if incomplete resection” per National Comprehensive Cancer Network (NCCN)
• For off-label cytokine release syndrome, removed option as replacement for second dose for immunotherapy related neurotoxicity and added option for usage in addition to toclizumab for grade 2-4 cytokine release syndrome per National Comprehensive Cancer Network (NCCN)
• Added off-label indication for Kaposi-sarcoma associated herpesvirus (KSHV)-associated inflammatory cytokine syndromeper National Comprehensive Cancer Network (NCCN)

Deflazacort (Emflaza) (CP.PHAR.331)

Ambetter

Policy updates include:

• Added requirement that request does not exceed health plan-approved quantity limit, if applicable
• Extended initial approval duration from 6 to 12 months for this maintenance medication for a chronic condition

Avelumab (Bavencio) (CP.PHAR.333)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• For Merkel cell carcinoma, added disease qualifier of locally advanced per National Comprehensive Cancer Network (NCCN)
• For off label indications per National Comprehensive Cancer Network (NCCN), revised disease qualifiers for thymic carcinoma, added option for combination with Inlyta for endometrial carcinoma, and added requirement for combination with Inlyta for salivary gland tumors
• For Medicaid and Ambetter lines of business, revised initial approval durations from 6 months to 12 months

Rucaparib (Rubraca) (CP.PHAR.350)

Ambetter

Policy updates include:

• For all indications, added requirement that request does not exceed health-plan approved quantity limit, revised quantity limit to 1,200mg per day and 4 tablets per day, extended Medicaid and Ambetter initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition
• For pancreatic adenocarcinoma, added off-label use in PALB2 mutations per National Comprehensive Cancer Network (NCCN)

Olaparib (Lynparza) (CP.PHAR.360)

Ambetter

Policy updates include:

• For all indications, added requirement that request does not exceed health-plan approved quantity limit, revised quantity limit to 600mg per day and 4 tablets per day, extended Medicaid and Ambetter initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition
• For breast cancer, added off-label use in deleterious germline PALB2 mutations per National Comprehensive Cancer Network (NCCN)
• For pancreatic adenocarcinoma, revised greater than (>) to greater than or equal to (≥) for platinum-based chemotherapy requirement and added prescribed as single agent therapy requirement
• For uterine neoplasms, added off-label use in mismatch repair proficient (pMMR) endometrial carcinoma per National Comprehensive Cancer Network (NCCN)

Tisagenlecleucel (Kymriah) (CP.PHAR.361)

Ambetter

Policy updates include:

• Added National Comprehensive Cancer Network (NCCN) Compendium supported off-label use in large B-cell lymphoma for Richter transformation and HIV-related plasmablastic lymphoma

Axicabtagene Ciloleucel (Yescarta) (CP.PHAR.362)

Ambetter

Policy updates include:

• Added National Comprehensive Cancer Network (NCCN) Compendium supported off-label use for large B-cell lymphoma in Richter transformation, primary mediastinal large B-cell lymphomafor Age less than 18 years, and human immunodeficiency virus (HIV)-related plasmablastic lymphoma
• Clarified for marginal zone lymphoma disease is refractory or member has relapsed after at least 2 lines of systemic therapy per National Comprehensive Cancer Network (NCCN) Compendium

Acalabrutinib (Calquence) (CP.PHAR.366)

Ambetter

Policy updates include:

• Added the following National Comprehensive Cancer Network (NCCN)-supported uses: first-line therapy for chronic lymphocytic leukemia/small lymphocytic lymphoma with Venclexta, single-agent therapy following Richter transformation
• Updated initial auth durations from 6 months to 12 months for Medicaid and Ambetter

Voretigene Neparvovec-rzyl (Luxturna) (CP.PHAR.372)

Ambetter

Policy updates include:

• Removed full-field stimulus testing testing requirement

Niraparib (Zejula) (CP.PHAR.408)

Ambetter

Policy updates include:

• For ovarian cancer, clarified requirements that member meets one of the following: member is in complete response or partial response or member has platinum-sensitive persistent or recurrent disease per National Comprehensive Cancer Network (NCCN)
• Removed capsules from criteria as formulation is obsolete and no longer available
• For all indications, added requirement that request does not exceed health-plan approved quantity limit, revised quantity limit to 300 mg per day and 1 tablet per day, extended Medicaid and Ambetter initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition
• Added off-label criteria for prostate cancer per National Comprehensive Cancer Network (NCCN) compendium

Talazoparib (Talzenna) (CP.PHAR.409)

Ambetter

Policy updates include:

• For all indications, added requirement that request does not exceed health-plan approved quantity limit, revised quantity limit to maximum dose per day and 1 capsule per day, extended Medicaid and Ambetter initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition

Bortezomib (Velcade) (CP.PHAR.410)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• For off-label indications per National Comprehensive Cancer Network (NCCN): added KICS indication, added disease qualifiers for Castleman disease and Kaposi sarcoma, added monotherapy requirement for adult T-cell leukemia/lymphoma, and removed requirement for use as subsequent therapy for pediatric acute lymphoblastic leukemia
• For Medicaid and Ambetter lines of business, revised initial approval durations from 6 months to 12 months

Glasdegib (Daurismo) (CP.PHAR.413)

Ambetter

Policy updates include:

• Per National Comprehensive Cancer Network (NCCN) guidelines removed use of Daurismo for relapsed/refractory disease
• Updated initial auth duration from 6 months to 12 months for Medicaid and Ambetter

Larotrectinib (Vitrakvi) (CP.PHAR.414)

Ambetter

Policy updates include:

• Added required use as a single agent
• Added approval pathway for members who failed or are not candidates for primary therapy (e.g., surgery, chemotherapy, or radiation)
• Added requirement that request does not exceed health-plan approved quantity limit
• Added dose maximum and prescriber attestation for concomitant use with CYP3A4 inducers
• Extended Medicaid and Ambetter initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition

Brolucizumab-dbll (Beovu) (CP.PHAR.445)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• For all indications, extended continued therapy approval duration from 6 months to 12 months for this maintenance medication for a chronic condition

Avapritinib (Ayvakit) (CP.PHAR.454)

Ambetter

Policy updates include:

• For gastrointestinal stromal tumor, added Qinlock, Sutent, and Stivarga as examples of prior lines of therapy
• For myeloid/lymphoid neoplasm with eosinophilia and FIP1L1- platelet-derived growth factor receptor (PDGFRA), revised criteria from “failure of imatinib” to “documentation of PDGFRA D842 mutation that is resistant to imatinib”
• Medicaid and Ambetter line of business, extended initial approval duration from 6 to 12 months for this maintenance medication for a chronic condition
• Added request does not exceed health plan-approved quantity limit, if applicable

Enfortumab Vedotin-ejfv (Padcev) (CP.PHAR.455)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Extended initial approval duration from 6 to 12 months for this maintenance medication for a chronic condition
• Added option to be prescribed in combination with Keytruda Qlex
• New indication for muscle invasive bladder cancer added per updated prescribing information.

Fam-Trastuzumab Deruxtecan-nxki (Enhertu) (CP.PHAR.456)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Added National Comprehensive Cancer Network (NCCN)-supported uses for recurrent non-small cell lung cancer (in addition to unresectable or metastatic), ampullary adenocarcinoma, pancreatic adenocarcinoma, and vaginal cancer
• Per National Comprehensive Cancer Network (NCCN) recs added a requirement for BRCA 1/2 negativity if using Enhertu for hormone-receptor-negative breast cancer as second-line or later therapy
• Updated initial auth durations from 6 months to 12 months for Medicaid and Ambetter
• Added approved indication for HR-positive, HER2-low or HER2-ultralow breast cancer.

Selumetinib (Koselugo) (CP.PHAR.464)

Ambetter

Policy updates include:

• For LCH, added option to be prescribed for LCH-associated abnormal central nervous system (CNS) imaging/neurodegeneration (LACI/ND) and clarified trial and failure of cobimetinib or trametinib only applies to adults
• Revised dose limit from 25 mg/m2 per day to 50 mg/m2 per day based on twice a day dosing
• Added request does not exceed health plan-approved quantity limit, if applicable
• Extended initial approval duration from 6 to 12 months for this maintenance medication for a chronic condition revised criteria for neurofibromatosis type 1 to reflect adult extension with removal of upper age limit

Valoctocogene Roxaparvovec-rvox (Roctavian) (CP.PHAR.466)

Ambetter

Policy updates include:

• Added qualifier that the 150 eds criterion applies to members who have had previous FVIII use
• Removed requirement for documentation of body weight

Zanubrutinib (Brukinsa) (CP.PHAR.467)

Ambetter

Policy updates include:

• For chronic lymphocytic leukemia/small lymphocytic lymphoma, added option to be prescribed in combination with Venetoclax per National Comprehensive Cancer Network (NCCN)
• Added off-label indication for primary central nervous system lymphoma per National Comprehensive Cancer Network (NCCN): add request does not exceed health plan-approved quantity limit, if applicable
• Extended initial approval duration from 6 to 12 months for this maintenance medication for a chronic condition

Belantamab Mafodotin-blmf (Blenrep) (CP.PHAR.469)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Policy reinstated due to Food and Drug Administration (FDA)’s accelerated approval in relapsed, refractory multiple myeloma in combination with dexamethasone and bortezomib.

Naxitamab-gqgk (Danyelza) (CP.PHAR.523)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Added treatment combination option with granulocyte-macrophage colony-stimulating factor, Temodar, and irinotecan per National Comprehensive Cancer Network (NCCN)
• Revised Medicaid and Ambetter initial approval duration to 12 months

Efgartigimod Alfa-fcab, Efgartigimod/Hyaluronidase-qvfc (Vyvgart, Vyvgart Hytrulo) (CP.PHAR.555)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• For generalized myasthenia gravis, clarified that immunosuppressive therapy should be non-steroidal
• For chronic inflammatory demyelinating polyneuropathy, revised “failure” to “insufficient response” for immune globulin therapy
• For continued criteria, clarified that generalized myasthenia gravis response criterion for 2-point reduction can also be greater than 2 points
• For concurrent therapy exclusions agents, added Imaavy
• For Medicaid and Ambetter lines of business, revised approval durations to 12 months

Antithrombin III (ATryn, Thrombate III) (CP.PHAR.564)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Atryn was discontinued and removed from criteria
• Updated Thrombate III indication for pediatric extension and removed requirement for age at least 18 years
• Revised approval durations for prevention from 6 months to 12 months

Asciminib (Scemblix) (CP.PHAR.565)

Ambetter

Policy updates include:

• Updated or added criteria in alignment with National Comprehensive Cancer Network (NCCN) recommendations: changed use for tyrosine kinase inhibitor (TKI)-experienced patients from those in accelerated phase to those in chronic phase, added a requirement for documentation of presence of ABL1 exon 2, added off-label use for Ph+ B-cell acute lymphoblastic leukemia
• Updated initial auth durations from 6 months to 12 months

Inclisiran (Leqvio) (CP.PHAR.568)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Reduced statin adherence duration from 4 months to 8 weeks
• Simplified statin trial and failure criteria for moderate- and low-intensity statin regimens to require insufficient therapeutic response to one high intensity statin for 8 weeks or reversible muscle-related symptoms associated with both rosuvastatin and atorvastatin
• Extended Medicaid and Ambetter initial approval duration from 9 months to 12 months for this maintenance medication for a chronic condition

Ropeginterferon Alfa-2b-njft (BESREMi) (CP.PHAR.570)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Added bypass language for states with regulations against step therapy in certain oncology settings
• Extended initial approval duration from 6 to 12 months for this maintenance medication for a chronic condition
• For PV, added option for usage as for use as substitute for peginterferon alfa-2a due to product unavailability per National Comprehensive Cancer Network (NCCN)
• Added off-label criterion for systemic mastocytosis, myelofibrosis, essential thrombocythemia, and chronic myeloid leukemia per National Comprehensive Cancer Network (NCCN)

Budesonide (Tarpeyo) (CP.PHAR.572)

Ambetter

Policy updates include:

• Removed requirement of one alternative systemic corticosteroid and revised criterion for proteinuria at least 0.5 g/day per updated Kidney Disease: Improving Global Outcomes (KDIGO) 2025 guidance 

Cabotegravir (Apretude), Cabotegravir/Rilpivirine (Cabenuva) (CP.PHAR.573)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Extended Medicaid and Ambetter initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition

Etranacogene Dezaparvovec-drlb (Hemgenix) (CP.PHAR.580)

Ambetter

Policy updates include:

• Added qualifier that the 150 EDS criterion applies to members who have had previous factor IX use
• Removed requirement for documentation of body weight

Faricimab-svoa (Vabysmo) (CP.PHAR.581)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• For neovascular (wet) age-related macular degeneration and diabetic macular edema, extended continued therapy duration from 6 months to 12 months for this maintenance medication for a chronic condition
• Clarified initial approval for retinal vein occlusion is for a total of 6 months of therapy (6 doses)

Zoledronic Acid (Reclast) (CP.PHAR.59)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Per competitor analysis for multiple myeloma, removed requirement that member is receiving or initiating therapy (e.g., chemotherapy, transplant) for symptomatic disease
• For initial approval revised approval duration for Medicaid and Ambetter from 6 to 12 months for multiple myeloma, solid tumor, systemic mastocytosis, and histiocytic neoplasms

Exagamglogene Autotemcel (Casgevy) (CP.PHAR.603)

Ambetter

Policy updates include:

• Added option of sickle cell disease genotype βs/β+ (hbs β+) for sickle cell disease
• Added genotype descriptors of hbss and hbs β0
• Removed requirement for documentation of body weight

Adagrasib (Krazati) (CP.PHAR.605)

Ambetter

Policy updates include:

• Added small bowel adenocarcinoma and appendiceal neoplasms as off-label indications per National Comprehensive Cancer Network (NCCN)
• Revised initial approval durations for Medicaid and Ambetter to 12 months

Furosemide (Furoscix) (CP.PHAR.608)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Added new dosage form Lasix ONYU

Teclistamab-cqyv (Tecvayli) (CP.PHAR.611)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Revised initial Medicaid and Ambetter approval duration to 12 months
• Added combination therapy option with Talvey for at least 3 prior lines of therapy per National Comprehensive Cancer Network (NCCN)
• For continued therapy, added dosing option for not exceeding 1.5 mg/kg every two weeks and if dose requested is 1.5 mg/kg per week, added requirement for documentation supporting member has not achieved and maintained a complete response or better for a minimum of 6 months

Tremelimumab-actl (Imjudo) (CP.PHAR.612)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Per National Comprehensive Cancer Network (NCCN) compendium– for non-small cell lung cancer, removed uses for RET rearrangement positive, EGFR exon 19 deletion, exon 21 L858R, ALK rearrangement positive, and ROSI rearrangement positive tumors
• Added recommended uses for NRG1 gene fusion positive tumors
• For gastric, esophageal, and esophagogastric junction cancer, clarified approval is for one dose
• For all indications, revised continued therapy section to not permit reauthorizations

Olutasidenib (Rezlidhia) (CP.PHAR.615)

Ambetter

Policy updates include:

• Added requirement for use as a single agent and added option for use for lower intensity therapy per National Comprehensive Cancer Network (NCCN)
• Extended initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition

Mosunetuzumab-axgb (Lunsumio) (CP.PHAR.618)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Per National Comprehensive Cancer Network (NCCN) Compendium added off-label use in additional B-cell lymphomas subtypes

Lovotibeglogene Autotemcel (Lyfgenia) (CP.PHAR.627)

Ambetter

Policy updates include:

• Added coverage for additional sickle cell disease genotypes βs/β0 (hbs β0) and βs/β+ (hbs β+)
• Removed requirement for documentation of body weight

Everolimus (Afinitor, Afinitor Disperz, Zortress) (CP.PHAR.63)

Ambetter

Policy updates include:

• Extended initial approval durations from 6 to 12 months for this maintenance medication for a chronic condition
• Added request does not exceed health plan-approved quantity limit, if applicable

ADAMTS13, Recombinant-krhn (Adzynma) (CP.PHAR.635)

Ambetter

Policy updates include:

• Removed requirement for plasma therapy failure per updated guideline
• Revised Medicaid and Ambetter initial approval duration for prophylaxis to 12 months and revised Commercial approval durations for prophylaxis to “6 months or to member’s renewal date, whichever is longer”

Sotatercept (Winrevair) (CP.PHAR.657)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Extended Medicaid and Ambetter initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition
• Revised Commercial approval duration to “6 months or to the member’s renewal date, whichever is longer”
• Added HCPCS codes J3590 and C9399

Capivasertib (Truqap) (CP.PHAR.663)

Ambetter

Policy updates include:

• Added use of Truqap for recurrence within 12 months of adjuvant therapy to align with its original Food and Drug Administration (FDA) approval
• Updated initial auth duration from 6 months to 12 months

Fruquintinib (Fruzaqla) (CP.PHAR.666)

Ambetter

Policy updates include:

• Extended initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition

Repotrectinib (Augtyro) (CP.PHAR.667)

Ambetter

Policy updates include:

• Clarified age restriction does not apply to pediatric diffuse high-grade glioma
• For all indications, extended initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition, added required use as a single agent
• Per National Comprehensive Cancer Network (NCCN) compendium– for NTRK fusion-positive cancer, added bypass for ampullary adenocarcinoma, brain metastases, esophageal and esophagogastric junction cancers, gastric cancer, pediatric diffuse high-grade glioma, and uterine sarcoma

Toripalimab-tpzi (Loqtorzi) (CP.PHAR.668)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Added National Comprehensive Cancer Network (NCCN) recommended off-label indications for anal carcinoma, small bowel adenocarcinoma, appendiceal neoplasms and cancers, colon cancer and rectal cancer per National Comprehensive Cancer Network (NCCN)
• Extended initial approval duration from 6 to 12 months for this maintenance medication for a chronic condition

Nirogacestat (Ogsiveo) (CP.PHAR.671)

Ambetter

Policy updates include:

• Extended initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition

Marstacimab-hncq (Hympavzi) (CP.PHAR.674)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Added clarification that requirement for hemophilia severity associated with factor level is taken at baseline prior to use of factor products for routine prophylaxis
• Revised provider confirmation of discontinuation of factor products as prophylaxis to exclusion for concurrent use of hemophilia prophylaxis agent with more examples
• Revised initial approval duration from 6 months to 12 months

Cosibelimab-Ipdl (Unloxcyt) (CP.PHAR.711)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Added option for satellitosis/in-transit metastasis per National Comprehensive Cancer Network (NCCN)
• Added criterion, prescribed as a single agent per National Comprehensive Cancer Network (NCCN)
• Extended initial approval duration from 6 to 12 months for this maintenance medication for a chronic condition

Plozasiran (Redemplo) (CP.PHAR.721)

Ambetter

Policy includes:

• Requests for indications not approved by the FDA are reviewed with the off-label use policy for the relevant line of business: HIM.PHAR.154 for Ambetter
• Initial Approval Criteria:  Familial Chylomicronemia Syndrome (FCS) (must meet all):
  • Diagnosis of FCS as evidenced by both of the following:
    • Fasting triglycerides at least 880 mg/dL or at least 10 mmol/L (lab must be dated within 90 days);
    • One of the following:
      • Genetic testing confirms the presence a loss-of-function mutation in an FCS-causing gene (e.g., LPL, APOC2, APOA5, GPIHBP1, LMF1);
      • History of elevated triglycerides in excess of 1,000 mg/dL at least three times, and one of the following:
        • History of pancreatitis;
        • Family history of hypertriglyceridemia;
        • History of recurrent abdominal pain without other explainable cause;
  • Prescribed by or in consultation with an endocrinologist, lipid specialist, or cardiologist;
  • Age at least 18 years;
  • Redemplo is not prescribed concurrently with Tryngolza;
  • Dose does not exceed 25 mg every 3 months.
  • Approval duration: 6 months
• Continued Therapy: Familial Chylomicronemia Syndrome (must meet all):
  • Member meets one of the following:
    • Currently receiving medication via Centene benefit or member has previously met initial approval criteria;
    • Member is currently receiving medication and is enrolled in a state and product with continuity of care regulations;
  • Member is responding positively to therapy as evidenced by reduction in fasting triglycerides from baseline;
  • If request is for a dose increase, new dose does not exceed 25 mg every 3 months.
  • Approval duration: 12 months

Doxecitine and doxribtimine (Kygevvi) (CP.PHAR.738)

Ambetter

Policy includes:

• Requests for indications not approved by the FDA are reviewed with the off-label use policy for the relevant line of business: HIM.PHAR.154 for Ambetter
• Initial Approval Criteria: Thymidine Kinase 2 Deficiency (must meet all):
  • Diagnosis of TK2d as evidenced by a mutation in the thymidine kinase 2 (TK2) gene;
  • Prescribed by or in consultation with a neurologist or metabolic disease specialist;
  • Age of symptom onset at most 12 years (e.g., proximal muscle weakness, respiratory weakness, facial diplegia);
  • Documentation of member’s current weight in kg;
  • Dose does not exceed doxecitine 400 mg/kg and doxribtimine 400 mg/kg per day
  • Approval duration: 12 months
  • Continued Therapy
  • Thymidine Kinase 2 Deficiency (must meet all):
    • Member meets one of the following:
    • Currently receiving medication via Centene benefit or member has previously met initial approval criteria;
    • Member is currently receiving medication and is enrolled in a state and product with continuity of care regulations;
  • Member is responding positively to therapy;
  • Documentation of member’s current weight in kg;
  • If request is for a dose increase, new dose does not exceed doxecitine 400 mg/kg and doxribtimine 400 mg/kg per day.
  • Approval duration: 12 months

Sevabertinib (Hyrnuo) (CP.PHAR.764)

Ambetter

Policy includes:

• Requests for indications not approved by the FDA are reviewed with the off-label use policy for the relevant line of business: HIM.PHAR.154 for Ambetter
• Initial Approval Criteria: Non-Small Cell Lung Cancer (NSCLC) (must meet all):
  • Diagnosis of recurrent, advanced (including locally advanced), or metastatic NSCLC;
  • Prescribed by or in consultation with an oncologist;
  • Age at least 18 years;
  • Prescribed as single agent;
  • Disease has activating HER2 (ERBB2) mutations;
  • Failure of a prior systemic;
  • Member has not previously experienced disease progression while on Hernexeos® (zongertinib);
  • For Hyrnuo requests, member must use sevabertinib, if available, unless contraindicated or clinically significant adverse effects are experienced;
  • Dose of Hyrnuo is at least 10 mg per day;
  • Request meets one of the following:*
    • Dose does not exceed 40 mg (4 tablets) per day;
    • Dose is supported by practice guidelines or peer-reviewed literature for the relevant off-label use (prescriber must submit supporting evidence). *Prescribed regimen must be FDA-approved or recommended by NCCN
  • Approval duration: 12 months
• Continued Therapy: Non-Small Cell Lung Cancer (must meet all):
  • Currently receiving medication via Centene benefit, or documentation supports that member is currently receiving Hyrnuo for a covered indication and has received this medication for at least 30 days;
  • Member is responding positively to therapy;
  • For Hyrnuo requests, member must use sevabertinib, if available, unless contraindicated or clinically significant adverse effects are experienced;
  • Dose of Hyrnuo is at least 10 mg per day;
  • If request is for a dose increase, request meets one of the following:*
    • New dose does not exceed 40 mg (4 tablets) per day;
    • New dose is supported by practice guidelines or peer-reviewed literature for the relevant off-label use (prescriber must submit supporting evidence. *Prescribed regimen must be FDA-approved or recommended by NCCN
  • Approval duration: 12 months

Ziftomenib (Komzifti) (CP.PHAR.765)

Ambetter

Policy includes:

• Requests for indications not approved by the FDA are reviewed with the off-label use policy for the relevant line of business: HIM.PHAR.154 for Ambetter
• Initial Approval Criteria: Acute Myeloid Leukemia (AML) (must meet all):
  • Diagnosis of relapsed or refractory AML;
  • Prescribed by or in consultation with an oncologist or hematologist;
  • Age at least 18 years;
  • Disease is positive for a NPM1 mutation;
  • Dose of Komzifti is at least 200 mg per day;
  • Prescribed as a single agent;
  • For Komzifti requests, member must use ziftomenib, if available, unless contraindicated or clinically significant adverse effects are experienced;
  • Request meets one of the following:*
    • Dose does not exceed 600 mg (3 capsules) per day;
    • Dose is supported by practice guidelines or peer-reviewed literature for the relevant off-label use (prescriber must submit supporting evidence). *Prescribed regimen must be FDA-approved or recommended by NCCN
  • Approval duration: 12 months
• Continued Therapy: Acute Myeloid Leukemia (must meet all):
  • Currently receiving medication via Centene benefit, or documentation supports that member is currently receiving Komzifti for a covered indication and has received this  medication for at least 30 days;
  • Member is responding positively to therapy;
  • Dose of Komzifti is at least 200 mg per day;
  • Prescribed as a single agent;
  • For Komzifti requests, member must use ziftomenib, if available, unless contraindicated or clinically significant adverse effects are experienced;
  • If request is for a dose increase, request meets one of the following:*
    • New dose does not exceed 600 mg (3 capsules) per day;
    • New dose is supported by practice guidelines or peer-reviewed literature for the relevant off-label use (prescriber must submit supporting evidence). *Prescribed regimen must be FDA-approved or recommended by NCCN
  • Approval duration: 12 months

Vandetanib (Caprelsa) (CP.PHAR.80)

Ambetter

Policy updates include:

• For differentiated thyroid carcinoma, added disease qualifiers of progressive and/or symptomatic, removed requirement for radioactive iodine therapy for oncocytic carcinoma, and revised status from “not amenable” to “refractory” per National Comprehensive Cancer Network (NCCN)
• Added request does not exceed health plan-approved quantity limit, if applicable
• Extended initial approval duration for Medicaid and Ambetter lines of business from 6 months to 12 months

Abiraterone (Zytiga, Yonsa) (CP.PHAR.84)

Ambetter

Policy updates include:

• Per National Comprehensive Cancer Network (NCCN) Compendium added off-label use in salivary gland tumor
• Revised initial approval duration for Medicaid and Ambetter in prostate cancer form 6 to 12 months
• Added template language “Request does not exceed health plan-approved quantity limit, if applicable”

Vemurafenib (Zelboraf) (CP.PHAR.91)

Ambetter

Policy updates include:

• Revised criteria to align with National Comprehensive Cancer Network (NCCN) guidelines: added BRAF V600E mutation requirement for off-label use for hairy cell leukemia, added grade 3 pleomorphic xanthoastrocytoma and high-grade astrocytoma with piloid features as covered uses
• Updated initial auth durations from 6 months to 12 months for Medicaid and Ambetter

Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) (CP.PHAR.94)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Added off-label indication of steroid-refractory acute GVHD per National Comprehensive Cancer Network (NCCN)
• For Medicaid and Ambetter, extended initial approval duration from 6 to 12 months for these maintenance medications for a chronic condition

Ruxolitinib (Jakafi, Opzelura) (CP.PHAR.98)

Ambetter

Policy updates include:

• Added request does not exceed health plan-approved quantity limit, if applicable for indications for Jakafi
• For Medicaid and Ambetter, extended initial and continued approval duration from 6 to 12 months for this maintenance medication for the chronic conditions of oncology (myelofibrosis, polycythemia vera, graft-versus-host diseas, myelodysplastic/myeloproliferative neoplasms, acute lymphoblastic leukemia, myeloid/lymphoid neoplasm, T-cell lymphomas) and essential thrombocythemia
• For polycythemia vera, added option to be prescribed as initial treatment for high-risk polycythemia vera
• For immunotherapy-related toxicities, added option to be prescribed for management of immune effector cell-parkinsonism and hemophagocytic lymphohistiocytosis-like syndrome

Safinamide (Xadago) (CP.PMN.113)

Ambetter

Policy updates include:

• Removed “idiopathic” as a Parkinson’s disease qualifier from diagnostic criterion
• Corrected reference from Appendix B to Appendix D for “off” time definition
• Revised initial approval duration from 6 months to 12 months
• For continued therapy, aligned initial therapy requirement for concurrent treatment with carbidopa/levodopa
• Revised Commercial approval duration to 12 months

Colchicine (Colcrys, Lodoco) (CP.PMN.123)

Ambetter

Policy updates include:

• Removed brand Colcrys from policy due to product discontinuation and its corresponding indications [familial mediterranean fever, treatment of acute gout attack, gout anti-inflammatory prophylaxis, pericarditis (off-label)]

Icosapent Ethyl (Vascepa) (CP.PMN.187)

Ambetter

Policy updates include:

• For all indications, added request does not exceed health-plan approved quantity limit, extended initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition
• For reduction of cardiovascular disease risk, reduced statin adherence duration from 4 months to 8 weeks, simplified statin trial and failure criteria for moderate- and low-intensity statin regimens to require insufficient therapeutic response to one high intensity statin for 8 weeks or reversible muscle-related symptoms associated with both rosuvastatin and atorvastatin
• References reviewed and updated

Istradefylline (Nourianz) (CP.PMN.217)

Ambetter

Policy updates include:

• Revised initial approval duration and continued approval duration for all lines of business to 12 months
• For continued therapy, aligned initial therapy requirement for concurrent treatment with carbidopa/levodopa

Bempedoic Acid (Nexletol), Bempedoic Acid/Ezetimibe (Nexlizet) (CP.PMN.237)

Ambetter

Policy updates include:

• Updated indication to reflect the following revised uses: as an adjunct to exercise (rather than low density lipoprotein cholesterol (LDL)-lowering therapy) for hefh for Nexlizet and to reduce major adverse cardiovascular events in adults at increased risk for these events (rather than adults with established cardiovascular disease) for both Nexlizet and Nexletol
• Revised “hyperlipidemia” to “hypercholesterolemia” throughout the criteria.

Varenicline (Tyrvaya) (CP.PMN.273)

Ambetter

Policy updates include:

• Extended initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition

Elinzanetant (Lynkuet) (CP.PMN.304)

Ambetter

Policy includes:

• Requests for indications not approved by the FDA are reviewed with the off-label use policy for the relevant line of business: HIM.PHAR.154 for Ambetter
• Initial Approval Criteria: Vasomotor Symptoms (must meet all):
  • Diagnosis of vasomotor symptoms associated with menopause;
  • Age at least 18 years;
  • Failure of two formulary estrogen products, unless contraindicated or clinically significant adverse effects are experienced;
  • Dose does not exceed 120 mg (2 capsules) per day.
  • Approval duration: 12 months
• Continued Therapy: Vasomotor Symptoms (must meet all):
  • Member meets one of the following:
    • Currently receiving medication via Centene benefit or member has previously met initial approval criteria;
    • Member is currently receiving medication and is enrolled in a state and product with continuity of care regulations;
  • Member is responding positively to therapy (e.g., vasomotor symptom reduction);
  • If request is for a dose increase, new dose does not exceed 120 mg (2 capsules) per day.
  • Approval duration: 12 months

Febuxostat (Uloric) (CP.PMN.57)

Ambetter

Policy updates include:

• Added request does not exceed health plan-approved quantity limit, if applicable
• For Medicaid, changed approval duration from length of benefit to 12 months

Buprenorphine/Naloxone (Suboxone, Zubsolv) (CP.PMN.81)

Ambetter

Policy updates include:

• Revised maximum dose limitation to 32 mg/8 mg for suboxone and 22.8 mg/5.8 mg for Zubsolv with option for usage exceeding 32 mg per day or 22.8 mg per day (buprenorphine component) for Suboxone or Zubsolv, respectively, with medical justification

Amantadine ER (Gocovri, Osmolex ER) (CP.PMN.89)

Ambetter

Policy updates include:

• Removed Osmolex ER from policy due to discontinuation
• For Parkinson’s disease with “off” episodes, moved the failure of immediate-release amantadine within the overall failure of two Parkinson’s disease adjunct drugs
• For continued therapy, aligned initial therapy requirement for concurrent treatment with carbidopa/levodopa
• Revised Commercial approval durations to 12 months

Secnidazole (Solosec) (CP.PMN.103)

Ambetter

Policy updates include:

• Added allowable time elapsed for bacterial vaginosis and trichomoniasis retreatment from continued therapy within initial criteria
• Added request does not exceed health plan-approved quantity limit, if applicable

Vorapaxar (Zontivity) (HIM.PA.146)

Ambetter

Policy updates include:

• Added requirement that request does not exceed health-plan approved quantity limit

Evolocumab (Repatha) (HIM.PA.156)

Ambetter

Policy updates include:

• For all indications, extended initial approval duration from 3 months to 12 months for this maintenance medication for a chronic condition

Evinacumab-dgnb (Evkeeza) (HIM.PA.166)

Ambetter

Policy updates include:

• Reduced statin adherence duration from 4 months to 8 weeks
• Simplified statin trial and failure criteria for moderate- and low-intensity statin regimens to require insufficient therapeutic response to one high intensity statin for 8 weeks or reversible muscle-related symptoms associated with both rosuvastatin and atorvastatin
• Extended initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (HIM.PA.58)

Ambetter

Policy updates include:

• Added requirement that request does not exceed health plan-approved quantity limit, if applicable

Dupilumab (Dupixent) (HIM.PA.SP69)

Ambetter

Policy updates include:

• Per National Comprehensive Cancer Network (NCCN) for immunotherapy-related toxicity, added option for G2 pruritus, added requirement for diagnostic confirmation of BP for bullous dermatitis, and removed corticosteroid requirement for bullous dermatitis
• For immunotherapy-related toxicity, revised approval durations from 6 to 12 months