Policy
| Applicable Products
| New Policy Overview or Updated Policy Revisions
|
Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Mycapssa) (CP.PHAR.40)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Added off-label criteria for Merkel cell carcinoma per National Comprehensive Cancer Network (NCCN)
- Revised language for Sandostatin LAR requests, from “member has received Sandostatin Injection” to “member will receive Sandostatin Injection”
- For Medicaid/Ambetter, extended initial approval duration from 6 to 12 months for this maintenance medication for a chronic condition
- Extended approval duration for Mycapssa for acromegaly for commercial line of business to 12 months
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Denosumab (Prolia, Xgeva), Denosumab-bbdz (Jubbonti, Wyost), Denosumab-dssb (Ospomyv, Xbryk), Denosumab-bmwo (CP.PHAR.58)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- For multiple myeloma, removed requirement that member is receiving or initiating therapy (e.g., chemotherapy, transplant) for symptomatic disease
- For giant cell tumor of the bone, added additional approval pathway for resectable disease where surgical resection is likely to result in severe morbidity
- For initial approval revised approval duration for Medicaid/Ambetter from 6 to 12 months for all oncology related indications
- Added new biosimilars Osvyrti and Jubereq to criteria
- Added Bilprevda as an additional preferred biosimilar
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Eculizumab (Soliris, Bkemv, Epysqli) (CP.PHAR.97)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Added redirection to Ultomiris
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Pegfilgrastim (Neulasta and biosimilars) (CP.PHAR.296)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Replaced Nyvepria with Fulphila as a preferred biosimilar
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Pasireotide (Signifor, Signifor LAR) (CP.PHAR.332)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Added redirection to all of the following: lanreotide, octreotide acetate LAR (generic Sandostatin LAR Depot), and brand Sandostatin LAR Depot if octreotide acetate LAR (generic Sandostatin LAR Depot) is unavailable due to shortage
- Removed Signifor LAR from non-formulary list which references usage of the formulary exception policy (HIM.PA.103)
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Pegvisomant (Somavert) (CP.PHAR.389)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Revised somatostatin analog redirection to failure of all of the following: lanreotide, octreotide acetate LAR (generic Sandostatin LAR Depot), and brand Sandostatin LAR Depot if octreotide acetate LAR (generic Sandostatin LAR Depot) is unavailable due to shortage.
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Lanreotide (Somatuline Depot) (CP.PHAR.391)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- For all indications, added redirection to octreotide acetate LAR (generic Sandostatin LAR Depot), added redirection to brand Sandostatin LAR Depot if octreotide acetate LAR is unavailable due to shortage, added member must use generic lanreotide if available for Somatuline Depot requests.
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Rilzabrutinib (Wayrilz) (CP.PHAR.751)
| Ambetter
| Policy updates include:
- Added redirection to generic Promacta for immune thrombocytopenia, removed redirection to immune globulin if intolerant or contraindicated to systemic corticosteroid.
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Paltusotide (Palsonify) (CP.PHAR.755)
| Ambetter
| Policy updates include:
- Added redirection to Mycapssa and one of lanreotide or generic octreotide acetate LAR (or brand Sandostatin LAR Depot if generic octreotide acetate LAR is unavailable due to shortage).
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Valganciclovir (Valcyte) (CP.PCH.06)
| Ambetter
| Policy updates include:
- For cytomegalovirus retinitis, changed approval duration from 4 months to 3 months per Centers for Disease Control (CDC) guidance
- Added request does not exceed health plan-approved quantity limit, if applicable
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Pegloticase (Krystexxa) (CP.PHAR.115)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Removed losartan as a uricosuric agent as its place in therapy is an antihypertensive alternative to hydrochlorothiazinde
- Added combination use with methotrexate per labeling
- Added prevention of concomitant use with pegadricase
- Extended initial approval duration from 6 to 12 months for Medicaid and Ambetter
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Alirocumab (Praluent) (CP.PHAR.124)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) and CHIP
| Policy updates include:
- For all indications, extended Medicaid initial approval duration from 3 months to 12 months for this maintenance medication for a chronic condition
- Removed pediatric use in hofh
- Updated indication to reflect the following revised uses: as an adjunct to exercise (rather than LDL-lowering therapy) for heterozygous familial hypercholesterolemia and homozygous familial hypercholesterolemia and to reduce major adverse cardiovascular events in adults at increased risk for these events (rather than adults with established cardiovascular disease)
- Revised “hyperlipidemia” to “hypercholesterolemia” throughout the criteria.
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Hemin (Panhematin) (CP.PHAR.181)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Added off-label indication for prevention of porphyria attacks
- For acute porphyria continued therapy, added criterion to ensure member has not received more than 14 days of treatment
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Glycerol Phenylbutyrate (Ravicti) (CP.PHAR.207)
| Ambetter
| Policy updates include:
- Added redirection to generic glycerol phenylbutyrate
- Added requirement for dietary protein restriction per labeling
- Extended initial approval duration from 6 to 12 months
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Sodium Phenylbutyrate (Buphenyl, Pheburane, Olpruva) (CP.PHAR.208)
| Ambetter
| Policy updates include:
- Added pediatric age extension to 1 year old for Olpruva
- Added requirement for dietary protein restriction per labeling
- Extended initial approval duration from 6 to 12 months
|
Desmopressin Acetate (DDAVP, Stimate, Nocdurna) (CP.PHAR.214)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- For hemophilia and Von Willebrand Disease surgical/acute bleeding, revised approval duration to 3 months and for Medicaid/Ambetter initial approval durations for all other indications, revised approval durations from 6 months to 12 months
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Dupilumab (Dupixent) (CP.PHAR.336)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) and CHIP
| Policy updates include:
- Per National Comprehensive Cancer Network (NCCN) for immunotherapy-related toxicity, added option for G2 pruritus, added requirement for diagnostic confirmation of bullous pemphigoid for bullous dermatitis, and removed corticosteroid requirement for bullous dermatitis
- For immunotherapy-related toxicity, revised approval durations from 6 to 12 months
|
Emicizumab-kxwh (Hemlibra) (CP.PHAR.370)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Revised provider confirmation of discontinuation of bypassing agents and FVIII products as prophylaxis to exclusion for concurrent use of hemophilia prophylaxis agent with more examples
- For Medicaid/Ambetter lines of business, revised initial approval durations from 6 months to 12 months
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Onasemnogene Abeparvovec (Zolgensma, Itvisma) (CP.PHAR.421)
| Ambetter
| Policy updates include:
- Added newly approved dosage form, Itvisma, with the following revisions: added documentation for inability to walk independently per study protocol
- Defined advanced spinal muscular atrophy for 2 years and older
- Added spinal muscular atrophy type 4 in section III
- Required 2 or 3 SMN2 copies.
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Luspatercept-aamt (Reblozyl) (CP.PHAR.450)
| Ambetter
| Policy updates include:
- For myelodysplastic syndromes with ring sideroblasts less than 15% scenario, added requirement for failure of Retacrit/Epogen unless serum erythropoietin greater than 200 mu/ml per National Comprehensive Cancer Network (NCCN) and added oncology step bypass
- Revised Medicaid/Ambetter initial approval duration for myelofibrosis-associated anemia and continued approval durations for transfusion dependent thalassemia and myelodysplastic syndromes to 12 months
- Revised Commercial approval durations for myelofibrosis-associated anemia initial approval and all continued therapy indications to “6 months or to the member’s renewal date, whichever is longer”
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Givosiran (Givlaari) (CP.PHAR.457)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Revised criterion regarding recurrent porphyria attacks from “at least 2 attacks in 6-month period” to “4 attacks per year” per American Gastroenterological Association guidelines
- Added criterion, “Panhematin, as a prophylactic treatment, is not prescribed concurrently with Givlaari” to continued therapy
- Extended initial approval duration from 6 to 12 months for this maintenance medication for a chronic condition
|
Lonafarnib (Zokinvy) (CP.PHAR.499)
| Ambetter
| Policy updates include:
- Added safety criteria regarding history of arrhythmias and QTc threshold per labeling updates
- Extended initial approval duration from 4 months for new starts to 12 months
|
Fostemsavir (Rukobia) (CP.PHAR.516)
| Ambetter
| Policy updates include:
- Extended initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition
|
Human Growth Hormone (Somapacitan, Somatrogon, Somatropin, Lonapegsomatropin-tcgd) (CP.PHAR.517)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) and CHIP
| Policy updates include:
- Removed Zorbtive from policy due to market discontinuation
- Removed criteria for short bowel syndrome due to lack of support by American Gastroenterological Association
- For human immunodeficiency virus (HIV) -associated wasting, added option for unintentional weight loss of at least 5% in the last 6 months while on antiretroviral and removed use of ideal body weight criteria per update 2024 consensus expert statement
- Extended initial approval duration from 6 to 12 months for this maintenance medication for a chronic condition
|
Sirolimus Protein-Bound Particles (Fyarro), Topical Gel (Hyftor) (CP.PHAR.574)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Per competitor analysis, for facial angiofibroma associated with tuberous sclerosis added requirement that member has three or more facial angiofibromas that are at least 2 mm in diameter with redness in each
- For pecoma revised initial approval duration for Medicaid/Ambetter to 12 months and for commercial “6 months or to the member’s renewal date, whichever is longer”
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Eladocagene Exuparvovec-tneq (Kebilidi) (CP.PHAR.595)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Restricted Kebilidi to age less than 11 years and member is unable to ambulate independently with or without assistive device based on current available evidence
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Futibatinib (Lytgobi) (CP.PHAR.604)
| Ambetter
| Policy updates include:
- Added 16 mg tablet strength
- Added minimum dose of 12 mg per day
- Extended initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition
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Zilucoplan (Zilbrysq) (CP.PHAR.616)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Clarified that the required immunosuppressive therapy should be non-steroidal
- Added Imaavy and Vyvgart Hytrulo to the list of therapies that Zilbrysq should not be prescribed concurrently with
- For Medicaid and Ambetter, extended approval durations from 6 to 12 months and for Commercial, revised approval durations to include “or to the member’s renewal date, whichever is longer” as generalized myasthenia gravis is a chronic condition
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Fitusiran (Qfitlia) (CP.PHAR.706)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Revised provider confirmation of discontinuation of bypassing agents and factor products as prophylaxis to exclusion for concurrent use of hemophilia prophylaxis agent with more examples
- For Medicaid and Ambetter, revised initial approval duration from 6 months to 12 months
|
Revumenib (Revuforj) (CP.PHAR.707)
| Ambetter
| Policy updates include:
- Added requirement for use as a single agent
- Extended initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition
- Added new Food and Drug Administration (FDA) approved indication for acute myeloid leukemia with nucleophosmin 1 (NPM1) mutation.
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Sepiapterin (Sephience) (CP.PHAR.708)
| Ambetter
| Policy updates include:
- Added adherent to Phe-restricted diet
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Zenocutuzumab-zbco (Bizengri) (CP.PHAR.713)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Extended initial approval duration for Ambetter/Medicaid from 6 to 12 months
- Added minimum left ventricular ejection fraction requirements per labeling
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Leuprolide Acetate (Eligard, Fensolvi, Lupron Depot, Lupron Depot-Ped, Vabrinty), Leuprolide Mesylate (Camcevi, Camcevi ETM) (CP.PCH.53)
| Ambetter
| Policy updates include:
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Cenegermin-bkbj (Oxervate) (CP.PMN.186)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Added diagnostic requirement for documented evidence of decreased corneal sensitivity
- Added requirement that disease is refractory to at least one conventional non-surgical treatment
- For continuation of therapy, for a second 8 week treatment course added requirement that member did not achieve complete corneal healing or has recurrence of neurotrophic keratitis in the affected eye that requires retreatment
- For initial approval criteria added requirement if member previously received Oxervate, member has not received at least 16 weeks total of Oxervate treatment per affected eye
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Sarecycline (Seysara) (CP.PMN.189)
| Ambetter
| Policy updates include:
- Added requirement for non-nodular and moderate-to-severe acne per labeling
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Bedaquiline (Sirturo) (CP.PMN.212)
| Ambetter
| Policy updates include:
- Revised age limit for use with pretomanid down to 14 years of age (from 15 years) per Infectious Diseases Society of America (IDSA)
- Removed allowance for use up to 9 months as these extended regimens only recommend bedaquiline be used for 24-26 weeks, not the entire extended treatment duration
- Per template added requirement that “request does not exceed health plan-approved quantity limit, if applicable”
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Pretomanid (CP.PMN.222)
| Ambetter
| Policy updates include:
- Revised age limit down to 14 years of age (from 15 years) per Infectious Diseases Society of America (IDSA)
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Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors (HIM.PA.91)
| Ambetter
| Policy updates include:
- For diabetes, revised canagliflozin-containing product bypass for trials of preferred SGLT2 inhibitors to require dapagliflozin for members with multiple risk factors for cardiovascular disease
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Human Growth Hormone (Somapacitan, Somatrogon, Somatropin) (HIM.PA.161)
| Ambetter
| Policy updates include:
- Removed Zorbtive from policy due to market discontinuation
- Removed criteria for short bowel syndrome due to lack of support by American Gastroenterological Association
- For human immunodeficiency virus (HIV)-associated wasting, added option for unintentional weight loss of at least 5% in the last 6 months while on antiretroviral and removed use of ideal body weight criteria per update 2024 consensus expert statement
- Extended initial approval duration from 6 to 12 months for this maintenance medication for a chronic condition
|
Mepolizumab (Nucala) (HIM.PA.175)
| Ambetter
| Policy updates include:
- For chronic obstructive pulmonary disease, revised blood eosinophil count requirement from “at least 150 cells/µl at time of request or at least 300 cells/µl in the past 12 months” to “at least 300 cells/µl” per 2026 Global Initiative for Chronic Obstructive Lung Disease (GOLD) chronic obstructive pulmonary disease guidelines
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