Effective June 1, 2026: Pharmacy and Biopharmacy Policies

Policy

Applicable Products

New Policy Overview or Updated Policy Revisions

Pegfilgrastim (Neulasta and biosimilars) (CP.PHAR.296)

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

Policy updates include:

• Added new biosimilar Armlupeg to policy
• Revised all Medicaid/Ambetter approval durations to 12 months

Desmopressin (DDAVP, Desmoda, Stimate, Nocdurna) (CP.PHAR.214)

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

Policy updates include:

• Added new oral solution Desmoda to policy.

Denosumab (Prolia, Xgeva and biosimilars) (CP.PHAR.58)

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

Policy updates include:

• Added new biosimilar Ponlimsi to criteria

Human Growth Hormone (Somapacitan, Somatrogon, Somatropin, Lonapegsomatropin-tcgd) (HIM.PA.161)

Ambetter

Policy updates include:

• Per updated label for Sogroya, added new pediatric indications for short stature born small for gestational age, growth failure associated with Noonan syndrome, and idiopathic short stature

Deutetrabenazine (Austedo, Austedo XR) (CP.PCH.42)

Ambetter

Policy updates include:

• Added Ingrezza Sprinkle to the concurrent use exclusion
• Revised initial approval durations from 6 to 12 months for Ambetter

Phendimetrazine (CP.PCH.47)

Ambetter

Policy updates include:

• For continued therapy, clarified positive response as evidenced by weight loss for adults and added reduction of body mass index for pediatrics

Immune Globulins (CP.PHAR.103)

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

Policy updates include:

• For Chimeric Antigen Receptor (CAR)-T cell-related toxicities, added use for acute inflammatory demyelinating polyneuropathy-type picture or bilateral facial palsy per (National Comprehensive Cancer Network (NCCN)
• Added off-label indications for immune checkpoint inhibitor-related toxicities, Langerhans cell histiocytosis (LCH)- associated abnormal, heparin-induced thrombocytopenia, and pediatric acute lymphoblastic leukemia per National Comprehensive Cancer Network (NCCN)
• Added HCPCS code [J1553]
• In Section III critical illness myopathy, removed “(necrotizing myopathy)” to avoid confusion with immune-mediated necrotizing myopathy (ICD10: G72.4)
• Revised bypass option for trial and failure of rituximab for dermatomyositis to juvenile dermatomyositis only (removed requirement for calcinosis) as intravenous immune globulin included as initial plan per CARRA consensus treatment. 

Regorafenib (Stivarga) (CP.PHAR.107)

Ambetter

Policy updates include:

• Per National Comprehensive Cancer Network (NCCN), revised the following – for colorectal cancer, specified that polymerase epsilon/delta (POLE/POLD1) mutation should have ultra-hypermutated phenotype
• For appendiceal carcinoma, moved out of colorectal cancer criteria to its own criteria set to reflect additional disease-specific recommendations for use
• For gastrointestinal stromal tumor, allowed resectable disease if succinate dehydrogenase (SDH)-deficient, and for combination therapy with Stivarga+everolimus, added disease qualifiers, requirement that disease is imatinib-sensitive KIT or PDGFRA mutant, and requirement for prior use of Stivarga as a single agent
• For soft tissue sarcoma, added borderline/malignant phyllodes tumor of the breast, epithelioid hemangioendothelioma, and pediatric rhabdomyosarcoma
• For uterine sarcoma, corrected “pegoma” to “pecoma”
• Removed off-label criteria for central nervous system cancers
• For all indications for Medicaid and Ambetter, extended initial approval duration from 6 to 12 months

Pomalidomide (Pomalyst) (CP.PHAR.116)

Ambetter

Policy updates include:

• For Kaposi sarcoma, added option for off-label use in Kaposi sarcoma-associated herpesviru -associated inflammatory cytokine syndrome if prescribed in combination with rituximab per National Comprehensive Cancer Network (NCCN)
• For all indication, extended Medicaid and Ambetter initial approval duration from 6 months to 12 months for this maintenance medication for chronic conditions

Encorafenib (Braftovi) (CP.PHAR.127)

Ambetter

Policy updates include:

• For melanoma, added option for use in stage III melanoma as neoadjuvant therapy
• For colon and rectal cancer, simplified to combination use with or without chemotherapy (capecitabine- or fluorouracil-based) per National Comprehensive Cancer Network (NCCN)
• Updated Food and Drug Administration (FDA) Approved Indication(s) section for mcrc from accelerated approval to full approval
• Added off-label criteria for small bowel adenocarcinoma and appendiceal neoplasms and cancer per National Comprehensive Cancer Network (NCCN) compendium
• For all indications, extended Medicaid and Ambetter initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition

Pegvaliase-pqpz (Palynziq) (CP.PHAR.140)

Ambetter/ICHRA

Policy updates include:

• Bringing forward to align with the annual review cycle for Kuvan
• Added adherence to Phe-restricted diet per plan feedback and align with Sephience criteria
• Updated criteria to reflect the newly Food and Drug Administration (FDA)-approved pediatric use for patients at least 12 years of age
• Added ICHRA line of business

Imiglucerase (Cerezyme) (CP.PHAR.154)

Ambetter

Policy updates include:

• Removed the age restriction for at least 2 years old based on the age group included in the analysis of the International Collaborative Gaucher Group Gaucher Registry which led to the Food and Drug Administration (FDA) approval of Cerezyme for type 3 Gaucher disease but which also included patients with type 1 Gaucher disease
• Updated initial approval duration from 6 months to 12 months
• Updated the Food and Drug Administration (FDA) Approved Indications section to reflect the recently Food and Drug Administration (FDA)-approved status of the type 3 Gaucher disease indication.

Teriparatide (Forteo, Bonsity) (CP.PHAR.188)

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

Policy updates include:

• Removed Ambetter and Commercial line of business
• Removed redirection to Tymlos or Prolia.

Pertuzumab (Perjeta), Pertuzumab-dpzb (Poherdy) (CP.PHAR.227)

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

Policy updates include:

• For breast cancer, added option to be prescribed in combination with Enhertu and added option for use of aromatase inhibitor with trastuzumab for postmenopausal or premenopausal receiving ovarian ablation or suppression
• Added off-label indication for brain metastases in breast cancer
• Small bowel adenocarcinoma, appendiceal neoplasms and cancers per National Comprehensive Cancer Network (NCCN)
• For all indications for Medicaid and Ambetter, extended initial approval duration from 6 to 12 months

Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase (CP.PHAR.228)

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

Policy updates include:

• For gastric, esophageal and esophagogastric junction cancer, added option for use in members who are not surgical candidates per National Comprehensive Cancer Network (NCCN)
• For endometrial carcinoma, added option for carcinosarcoma histology
• Added off-label indication for brain metastasis due to breast cancer
• Appendiceal neoplasms
• And small bowel adenocarcinoma per National Comprehensive Cancer Network (NCCN)
• For all indications for Medicaid and Ambetter, extended initial approval duration from 6 to 12 months

OnabotulinumtoxinA (Botox) (CP.PHAR.232)

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

Policy updates include:

• For chronic migraine, simplified criteria for concurrent use with calcitonin gene-related peptide (CGRP) to member has had a reduction in the overall migraine headache days per month with calcitonin gene-related peptide (CGRP) monotherapy and provider attestation of a significant number of migraine headache days despite calcitonin gene-related peptide (CGRP) monotherapy.

Dabrafenib (Tafinlar) (CP.PHAR.239)

Ambetter

Policy updates include:

• For B-Raf proto-oncogene, serine/ threonine kinase (BRAF) V600E mutation-positive solid tumor per National Comprehensive Cancer Network (NCCN), removed “as subsequent treatment” from ampullary adenocarcinoma to allow first-line treatment and clarified requirement that disease is not amenable to radioactive iodine therapy for follicular and papillary thyroid carcinoma only
• For off-label National Comprehensive Cancer Network (NCCN) compendium indications, added pediatric Langerhans cells histiocytosis and pediatric Langerhans cells histiocytosis-associated abnormal central nervous system imaging/neurodegeneration
• For all indications, extended Medicaid and Ambetter initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition

Trametinib (Mekinist) (CP.PHAR.240)

Ambetter

Policy updates include:

• For B-Raf proto-oncogene, serine/ threonine kinase (BRAF) V600E mutation-positive solid tumor per National Comprehensive Cancer Network (NCCN), removed “as subsequent treatment” from ampullary adenocarcinoma to allow first-line treatment, clarified small bowel adenocarcinoma is advanced or metastatic, added option for use as a single agent in adult circumscribed glioma, clarified requirement that disease is not amenable to radioactive therapy for follicular and papillary thyroid carcinoma only
• For off-label National Comprehensive Cancer Network (NCCN) compendium indications, added criteria for pediatric Langerhans cells histiocytosis and pediatric Langerhans cells histiocytosis-associated abnormal central nervous system imaging/neurodegeneration, added criteria for epithelioid hemangioendothelioma
• Extended Medicaid and Ambetter initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition

Adalimumab (Humira), Adalimumab-afzb (Abrilada), Adalimumab-atto (Amjevita), Adalimumab-adbm (Cyltezo), Adalimumab-bwwd (Hadlima), Adalimumab-fkjp (Hulio), Adalimumab-adaz (Hyrimoz), Adalimumab-aacf (Idacio), Adalimumab-ryvk (Simlandi), Adalimumab-aaty (Yuflyma), Adalimumab-aqvh (Yusimry) (CP.PHAR.242)

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

Policy updates include:

• Applied Idacio’s pediatric age extensions for hidradenitis suppurativa and uveitis

Ustekinumab (Stelara), Ustekinumab-aauz, Ustekinumab-srlf (Imuldosa), (Otulfi), Ustekinumab-ttwe (Pyzchiva), Ustekinumab-aekn (Selarsdi), Ustekinumab-hmny (Starjemza), Ustekinumab-stba (Steqeyma), Ustekinumab-auub (Wezlana), Ustekinumab-kfce (Yesintek) (CP.PHAR.264)

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

Policy updates include:

• Added newly approved autoinjector formulation for Pyzchiva
• Added newly approved single-dose vial for subcutaneous injection for Selarsdi

Vismodegib (Erivedge) (CP.PHAR.273)

Ambetter

Policy updates include:

• Clarified metastatic basal cell carcinoma does not require additional requirement of disease recurrence following surgery/radiation or that member is not a candidate for surgery or radiation
• Extended Medicaid and Ambetter initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition

Ofatumumab (Arzerra, Kesimpta) (CP.PHAR.306)

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

Policy updates include:

• For chronic lymphocytic leukemia, clarified that maximum dose also applies to duration as noted in section V
• For Medicaid and Ambetter, extended initial approval durations from 6 to 12 months for this maintenance medication for a chronic condition

Ipilimumab (Yervoy) (CP.PHAR.319)

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

Policy updates include:

• For melanoma, non-small cell lung cancer, malignant pleural mesothelioma, esophageal squamous cell carcinoma, and off-label National Comprehensive Cancer Network (NCCN) compendium indications, extended Medicaid and Ambetter initial approval durations from 6 months to 12 months for this maintenance medication for a chronic condition, extended Commercial initial approval duration is “6 months or to the member’s renewal data, whichever is longer”
• For non-small cell lung cancer, malignant pleural mesothelioma, and esophageal squamous cell carcinoma continued therapy, added criterion for maximum duration of therapy limit of 2 years and extended Commercial approval duration is “6 months or to the member’s renewal data, whichever is longer”
• For esophageal squamous cell carcinoma, added option to be prescribed as induction therapy
• For off-label National Comprehensive Cancer Network (NCCN) compendium indications, removed use as a single agent for soft tissue sarcoma, added off-label indications for appendiceal neoplasms and cancers, small bowel adenocarcinoma with polymerase epsilon/delta (POLE/POLD) mutation, cervical cancer, neuroendocrine and adrenal tumors, uterine neoplasms, vaginal cancer, and vulvar cancer, extended Commercial continued therapy approval duration is “6 months or to the member’s renewal data, whichever is longer”

Nusinersen (Spinraza) (CP.PHAR.327)

Ambetter

• 2Q 2026 annual review: no significant changes; clarified “at least” 6 months of trial prior to treatment change per 2025 AAN SMA update; added Itvisma, a newly approved one-time intrathecal version of Zolgensma, as another example for no concurrent use; added HFMSE as an alternative option for demonstrating prior treatment response; references reviewed and updated.

Dupilumab (Dupixent) (CP.PHAR.336)

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

Policy updates include:

• Added new indication for allergic fungal rhinosinusitis per updated prescribing information.

Durvalumab (Imfinzi) (CP.PHAR.339)

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

Policy updates include:

• Per National Comprehensive Cancer Network (NCCN), revised the following – for non-small cell lung cancer, added option for use after completion of adjuvant chemoradiation
• For small cell lung, added option for use in combination with etoposide and carboplatin or cisplatin as subsequent treatment for progression or relapse if member had prolonged disease free time
• For biliary tract cancer, added option for use in combination with carboplatin if cisplatin ineligible
• For hepatocellular carcinoma, added option for use as subsequent-line therapy and added requirement for use as a single agent or in combination with Imjudo
• For endometrial cancer, added option for use in mismatch repair proficient (pMMR) disease in combination with Lynparza
• For gastric or gastroesophageal junction adenocarcinoma, removed requirement for programmed death-ligand (PD-L1) combined positive score or tumor area positivity
• Added off-label criteria for small bowel adenocarcinoma

Midostaurin (Rydapt) (CP.PHAR.344)

Ambetter

Policy updates include:

• For systemic mastocytosis, added off-label use in well-differentiated systemic mastocytosis per National Comprehensive Cancer Network (NCCN)
• For Medicaid and Ambetter, extended initial approval durations from 6 to 12 months

Alectinib (Alecensa) (CP.PHAR.369)

Ambetter

Policy updates include:

• For resected non-small cell lung cancer, revised cancer staging to include IB per National Comprehensive Cancer Network (NCCN) and removed corresponding tumor and lymph node staging
• For anaplastic large cell lymphoma, added option for subsequent therapy for progressive disease per National Comprehensive Cancer Network (NCCN)
• Revised initial and continued approval durations for Medicaid/Ambetter to 12 months

Cobimetinib (Cotellic) (CP.PHAR.380)

Ambetter

Policy updates include:

• For histiocytic neoplasms, added option for use in disease that is positive for mitogen-activated protein (MAP) kinase pathway mutation, has no detectable mutation, or testing is not available
• Extended Medicaid and Ambetter initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition

Lorlatinib (Lorbrena) (CP.PHAR.406)

Ambetter

Policy updates include:

• For ROS1 positive non-small cell lung cancer, added Ibtrozi as a failure option and clarified that failure is required for one of the listed agents with the addition of “or” per National Comprehensive Cancer Network (NCCN)
• Added maximum dose option of 125 mg per day if receiving a moderate CYP3A4 inducer and removed tablet quantity limit to accommodate dose adjustments
• For anaplastic large cell lymphoma, added clarification that Lorbrena is subsequent therapy for relapsed, or refractory, or progressive disease and added palliative treatment as an option per National Comprehensive Cancer Network (NCCN)
• Revised initial approval durations for Medicaid/Ambetter to 12 months

Elapegademase-lvlr (Revcovi) (CP.PHAR.419)

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

Policy updates include:

• Moved examples of positive response to therapy from Appendix D into Continued Therapy criteria section
• Revised initial approval duration for Medicaid/Ambetter to 12 months

Cladribine (Mavenclad) (CP.PHAR.422)

Ambetter

Policy updates include:

• Incorporated existing treatment course limitations from approval duration into criteria
• Added primary progressive multiple sclerosis to section III to align with other multiple sclerosis agents
• References reviewed and updated

Nadofaragene firadenovec-vncg (Adstiladrin) (CP.PHAR.461)

Ambetter

Policy updates include:

• Removed lifetime dose requirement, clarified frequency does not exceed every 3 months, removed specification of “a single dose.”

Sacituzumab Govitecan-hziy (Trodelvy) (CP.PHAR.475)

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

Policy updates include:

• For triple-negative breast cancer, added option to be prescribed as first-line therapy per National Comprehensive Cancer Network (NCCN)
• For all indications for Medicaid and Ambetter, extended initial approval duration from 6 to 12 months

Risdiplam (Evrysdi) (CP.PHAR.477)

Ambetter

Policy updates include:

• Clarified “at least” 6 months of trial prior to treatment change per 2025 American Academy of Neurology (AAN) spinal muscular atrophy update
• Added Itvisma, a newly approved one-time intrathecal version of Zolgensma, as another example for no concurrent use
• Added Hammersmith functional
• motor scale expanded (HFMSE) as an alternative option for demonstrating prior treatment response2q 2026 annual review:

Selpercatinib (Retevmo) (CP.PHAR.478)

Ambetter

Policy updates include:

• Added tablet/capsule quantity limit bypass for documentation supporting inability to swallow oral capsules/tablets
• Revised initial approval durations for Medicaid/Ambetter to 12 months

Isatuximab-irfc (Sarclisa) (CP.PHAR.482)

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
• Extended Commercial approval duration from 6 months to “6 months or to the member’s renewal date, whichever is longer”
• Added off-label indication for primary therapy in combination with lenalidomide and dexamethasone per National Comprehensive Cancer Network (NCCN)

Binimetinib (Mektovi) (CP.PHAR.50)

Ambetter

Policy updates include:

• For histiocytic neoplasms, removed age requirement to allow use in pediatric population per National Comprehensive Cancer Network (NCCN)
• For all indications, extended Medicaid and Ambetter initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition

Pralsetinib (Gavreto) (CP.PHAR.514)

Ambetter/ICHRA

Policy updates include:

• Added Ambetter line of business
• For thyroid carcinoma, clarified differentiated thyroid carcinoma into follicular, oncocytic, and papillary carcinoma, removed redundant criteria for disease not amenable to radioactive iodine, added option for use in locoregional or metastatic disease without prior radioactive iodine therapy for oncocytic carcinoma and anaplastic thyroid carcinoma
• Added ICHRA line of business

Insulin Delivery Systems (V-Go, Omnipod, InPen) (CP.PHAR.534)

Ambetter

Policy updates include:

• Revised insulin administration method criterion to require duration only for multiple daily insulin injections
• For V-Go and Omnipod Pods, revised initial approval duration for Medicaid and Ambetter from 6 to 12 months
• Added exception to prescriber requirement for Oregon requests per health plan request due to endocrinologist shortage
• Reduced duration requirement for insulin administration method for multiple daily insulin injections from 6 months to 3 months, reduced duration requirement for blood glucose monitoring from 6 months to 2 months.

Tivozanib (Fotivda) (CP.PHAR.538)

Ambetter

Policy updates include:

• Revised “at least 2 prior systemic therapies” to “prior systemic therapy” per National Comprehensive Cancer Network (NCCN)
• For Medicaid and Ambetter, extended initial approval duration from 6 to 12 months

Beremagene Geperpavec (Vyjuvek) (CP.PHAR.592)

Ambetter

Policy updates include:

• For initial approval criteria and continued therapy, added “on the same target wound” to clarify Vyjuvek is not used concurrently on the same wound as Filsuvez and Zevaskyn.

Donanemab-azbt (Kisunla) (CP.PHAR.594)

Ambetter

Policy updates include:

• Removed the requirement for follow-up magnetic resonance imaging in the Continued Therapy section
• Added Leqembi Iqlik as a recently Food and Drug Administration (FDA)-approved alternative formulation of Leqembi that should not be used concomitantly with Kisunla
• Extended initial and continued approval durations to 6 and 12 months, respectively for Medicaid/Ambetter, with 6 months or renewal date for Commercial reauthorizations.

Lecanemab-irmb (Leqembi) (CP.PHAR.596)

Ambetter

Policy updates include:

• Removed the requirement for follow-up magnetic resonance imaging in the Continued Therapy section
• Added Leqembi Iqlik as a recently Food and Drug Administration (FDA)-approved alternative formulation of Leqembi that should not be used concomitantly with Kisunla
• Extended initial and continued approval durations to 6 and 12 months, respectively for Medicaid/Ambetter, with 6 months or renewal date for Commercial reauthorizations.

Prademagene Zamikeracel (Zevaskyn) (CP.PHAR.609)

Ambetter

Policy updates include:

• Added criteria “on the same target wound” to clarify Zevaskyn is not used concurrently on the same wound as Vyjuvek and Filsuvez.

Concizumab-mtci (Alhemo) (CP.PHAR.625)

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

Policy updates include:

• Removed requirements for documentation and provider attestations of Concizumab ELISA
• For hemophilia A or B without inhibitors, added clarification that hemophilia severity associated with factor level is taken at baseline prior to use of factor products for routine prophylaxis
• Modified initial approval durations for Medicaid/Ambetter to 12 months and for Commercial to “6 months or to the member’s renewal date, whichever is longer” as this is a maintenance medication for a chronic condition

Retifanlimab-dlwr (Zynyz) (CP.PHAR.629)

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

Policy updates include:

• Added off-label criteria for appendiceal neoplasms and cancers per National Comprehensive Cancer Network (NCCN)
• Simplified National Comprehensive Cancer Network (NCCN) off-label uses under section “National Comprehensive Cancer Network (NCCN) Recommended Uses (off-label)”

Sparsentan (Filspari) (CP.PHAR.631)

Ambetter

Policy updates include:

• Revised criterion for proteinuria at least 0.5 g/day per updated Kidney Disease: Improving Global Outcomes (KDIGO) 2025 guidance

Topotecan (Hycamtin) (CP.PHAR.64)

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

Policy updates include:

• For all indications, extended Medicaid and Ambetter initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition
• For off-label National Comprehensive Cancer Network (NCCN) recommendations, revised neuroblastoma to include non-induction therapy

Aprocitentan (Tryvio) (CP.PHAR.676)

Ambetter

Policy updates include:

• For initial approval criteria, revised BP threshold from at least 140/90 mmHg to at least 130/80 mmHg per 2025 American College of Cardiology/American Heart Association (ACC/AHA) guideline, added pathway for use in BP less than 130/80 mmHg if adherent to and prescribed concurrently with four or more antihypertensive drug classes
• Extended initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition

Lenalidomide (Revlimid) (CP.PHAR.71)

Ambetter

Policy updates include:

• Revised the following per National Comprehensive Cancer Network (NCCN) – for multiple myeloma, added options for use for treatment of monoclonal immunoglobulin
• deposition disease, monoclonal gammopathy of renal, and central nervous system system disease, and simplified use for treatment of polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, skin change (POEMS)
• For marginal zone lymphomas, added option for use for extranodal marginal zone lymphomas
• For follicular lymphoma, added option for use in combination with rituximab and Epkinly
• For off-label uses, added option for use for primary vitreoretinal lymphoma/primary central nervous system
• Lymphoma ocular variant, Rosai-Dorfman disease, Karposi Sarcoma (KS)-associated herpes virus associated inflammatory cytokine syndrome, and mycosis fungoides/Sezary syndrome
• For all indications for Medicaid and Ambetter, extended initial approval duration from 6 to 12 months

Copper Histidinate (Zycubo (CP.PHAR.714)

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

Policy updates include:

• Drug is now Food and Drug Administration (FDA)-approved – criteria updated per Food and Drug Administration (FDA) labeling
• Added upper age limit of 17 years
• Added requirement for documentation of baseline (within the last 30 days) serum copper and ceruloplasmin levels
• Added requirement that member does not have occipital horn syndrome
• For continued therapy positive response, added serum levels or neurologic symptom parameters.

Datopotamab Deruxtecan-dlnk (Datroway) (CP.PHAR.715)

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

Policy updates include:

• Added criteria for triple-negative breast per National Comprehensive Cancer Network (NCCN)
• For all indications for Medicaid and Ambetter, extended initial approval duration from 6 to 12 months

Dasatinib (Sprycel, Phyrago) (CP.PHAR.72)

Ambetter

Policy updates include:

• Added National Comprehensive Cancer Network (NCCN) compendium supported use in Grade 4 cytokine release syndromethat is refractory to high-dose corticosteroids and anti-IL-6 therapy
• Generic dasatinib is now available, so clarified generic redirection by removing ‘if available’
• For Medicaid/Ambetter revised initial approval duration from 6 to 12 months

Atrasentan (Vanrafia) (CP.PHAR.727)

Ambetter

Policy updates include:

• Revised proteinuria criterion from 1 g/day to 0.5 g/day per updated 2025 Kidney Disease: Improving Global Outcomes (KDIGO) guidelines
• Extended initial approval duration from 6 to 12 months for this maintenance medication for a chronic condition

Erlotinib (Tarceva) (CP.PHAR.74)

Ambetter

Policy updates include:

• For kidney cancer, removed single-agent therapy option per National Comprehensive Cancer Network (NCCN)
• Revised initial approval durations for Medicaid/Ambetter to 12 months

Temozolomide (Temodar) (CP.PHAR.77)

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

Policy updates include:

• For off-label National Comprehensive Cancer Network (NCCN) Compendium, added criteria for metastatic Ewing sarcoma, neuroblastoma in combination with irinotecan, naxitamab-gqgk, and sargramostim, borderline/malignant phyllodes tumor of the breast, epithelioid hemangioendothelioma, mucosal melanoma, adult high-grade glioma, and leptomeningeal metastases
• For all indications, extended initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition

Dalnacogene Ponparvovec (BBM-H901) (CP.PHAR.771)

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

Policy includes:

• Criteria will mirror the clinical information from the prescribing information once FDA-approved
• Criteria is only applicable for Medicaid and CHIP when the drug is added to the medical benefit for coverage
• 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, and CP.PMN.53 for Medicaid and CHIP
• Initial Approval Criteria*
  *Criteria will mirror the clinical information from the prescribing information once FDA-approved
  • Congenital hemophilia B (must meet all):
    • Diagnosis of congenital hemophilia B (factor IX deficiency);*
    • Prescribed by or in consultation with a hematologist;
    • Age at least 18 years;*
    • Member has severe or moderately severe hemophilia (defined as a factor IX level of at most 2%);*
    • Member meets one of the following:
      • Adherence to current use of a factor IX product* (e.g., Alprolix®, Benefix®, Idelvion®, Ixinity®, Rebinyn®, Rixubis®) for routine prophylaxis as assessed and documented by prescriber;
      • Has current or historical life-threatening hemorrhage;
      • Has repeated, serious spontaneous bleeding episodes;
    • Member has been treated with factor IX product for a minimum of 100 exposure days;*
    • Member meets all of the following:*
      • No previous documented history of a detectable factor IX inhibitor;
      • Documentation of inhibitor level assay less than 0.6 Bethesda units (BU) within the last 12 months;
      • If member had an initial positive test result for factor IX inhibitor, member has documentation of a subsequent negative test within 2 weeks;
    • Member has had all of the following baseline liver assessments within the last 3 months:*
      • Documentation of liver enzymes at most 1.5x the upper limit of normal (i.e., alanine aminotransferase [ALT], aspartate aminotransferase [AST], alkaline phosphatase [ALP], and total bilirubin);
      • Documentation of normal hepatic ultrasound and elastography;
      • If member has evidence of radiological liver abnormalities and/or sustained liver enzyme elevations, attestation from hepatologist that member is eligible for BBM-H901;
    • Member does not have a history of allergic reactions to immunoglobulin administration;*
    • Member has not received prior gene therapy;
    • Member has been tested for neutralizing anti-adeno-associated virus serotype 843 (AAV843) antibodies and is deemed a suitable candidate for treatment;*
    • Documentation of member’s body weight in kg;
    • Dose does not exceed a single IV infusion of 5 x 1012 vector genomes (vg) per kg.*
  • Approval duration: 3 months (1 dose only)

• Continued Therapy
  • Congenital Hemophilia B
    • Continued therapy will not be authorized as BBM-H901 is indicated to be dosed one time only

Doruxapapogene Ralaplasmid (INO-3107) (CP.PHAR.772)

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

Policy includes:

• Criteria will mirror the clinical information from the prescribing information once FDA-approved
• Criteria is only applicable for Medicaid and CHIP when the drug is added to the medical benefit for coverage
• 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, and CP.PMN.53 for Medicaid and CHIP
• Initial Approval Criteria*
  *Criteria will mirror the clinical information from the prescribing information once FDA-approved
  • Respiratory Papillomatosis (must meet all):
    • Diagnosis of RRP;
    • Diagnosis is confirmed by tissue biopsy;
    • Prescribed by or in consultation with an otolaryngologist or pulmonologist;
    • Age at least 18 years;
    • In the previous 12 months, member has had at least 2 interventions (surgical resection or laser ablation) aimed at reducing voice and airway symptoms caused by the papilloma;
    • If age at most 45 years, member has previously completed the HPV vaccination series, unless contraindicated or clinically significant adverse effects are experienced;
    • Prior to initiation of INO-3107 treatment, member is scheduled to undergo an endoscopic surgical debulking procedure to remove laryngotracheal papilloma;
    • Member has not previously received treatment with INO-3107 or Papzimeos™;
    • INO-3107 is not prescribed concurrently with Papzimeos;
    • Dose does not exceed four total doses of 6.25 mg.
  • Approval duration: 6 months

• Continued Therapy*
  *Criteria will mirror the clinical information from the prescribing information once FDA-approved
  • Respiratory Papillomatosis
    • Continued therapy will not be authorized as INO-3107 is indicated to be dosed as a single treatment course (four doses lifetime) only.
  • Approval duration: Not applicable

Veligrotug (VRDN-001) (CP.PHAR.773)

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

Policy includes:

• Criteria will mirror the clinical information from the prescribing information once FDA-approved
• Criteria is only applicable for Medicaid and CHIP when the drug is added to the medical benefit for coverage
• 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, and CP.PMN.53 for Medicaid and CHIP
• Initial Approval Criteria*
  *Criteria will mirror the clinical information from the prescribing information once FDA-approved
  • Thyroid Eye Disease (must meet all):
    • Diagnosis of Graves’ disease with associated TED (i.e., Graves’ ophthalmopathy, Graves’ orbitopathy);
    • Prescribed by or in consultation with an ophthalmologist;
    • One of the following:
      • Member is euthyroid with documentation of a recent (within the last 30 days) free thyroxine (FT4) and total triiodothyronine (T3) or free T3 (FT3) levels within the laboratory defined reference range;
      • Member has a recent (within the last 30 days) free thyroxine (FT4) and total triiodothyronine (T3) or free T3 (FT3) levels less than 50% above or below the laboratory defined reference range and is undergoing treatment to correct the mild hypo- or hyperthyroidism to maintain a euthyroid state;
    • Member has not had previous surgical intervention for TED;
    • Member does not require surgical ophthalmological intervention;
    • Failure of a 4-week trial of a systemic corticosteroid (at up to maximally indicated doses), unless one of the following:*
      • Clinically significant adverse effects are experienced or all are contraindicated;
      • Member has significant proptosis (examples may include but are not limited to proptosis at least 3 mm above the upper limit for race and sex, or proptosis that impacts activities of daily life [e.g., reading, driving, computer work, and watching television]);
      • Member has diplopia;
    • VRDN-001 is not prescribed concurrently with Tepezza™;
    • Member has not received at least 5 VRDN-001 infusions;
    • Dose does not exceed a total of five 600 mg infusions given every 3 weeks.
  • Approval duration: 6 months (up to 5 total lifetime infusions)
• Continued Therapy*
  *Criteria will mirror the clinical information from the prescribing information once FDA-approved
  • Thyroid Eye Disease (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 has not had previous surgical intervention for TED;
    • Member does not require surgical ophthalmological intervention;
    • VRDN-001 is not prescribed concurrently with Tepezza™;
    • Member has not received at least 5 VRDN-001 infusions;
    • If request is for a dose increase, new dose does not exceed five 600 mg infusions given every 3 weeks.
  • Approval duration: 1 month (up to 5 total lifetime infusions)

Vusolimogene Oderparepvec (RP1) (CP.PHAR.774)

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

Policy includes:

• Criteria will mirror the clinical information from the prescribing information once FDA-approved
• Criteria is only applicable for Medicaid and CHIP when the drug is added to the medical benefit for coverage
• 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, and CP.PMN.53 for Medicaid and CHIP
• Initial Approval Criteria*
  *Criteria will mirror the clinical information from the prescribing information once FDA-approved
  • Cutaneous Melanoma (must meet all):
    • Diagnosis of unresectable Stage IIIb-IV cutaneous melanoma;*
    • Prescribed by or in consultation with an oncologist;
    • Age at least 18 years;*
    • Documentation of disease progression, inadequate response, or intolerance while on a regimen containing both of the following:*
      • Anti-PD-1 therapy;
      • Anti-CTLA-4 therapy, unless member is not a candidate for anti-CTLA-4 therapy;
    • RP1 is prescribed in combination with nivolumab*;
    • Documentation that member has at least one measurable and injectable lesion comprising at least 1 cm in the longest diameter;*
    • Member has not been previously treated with Imlygic®;*
    • Request meets one of the following:*
      • Dose does not exceed both of the following:*
        • Initial dose of 1 x 106  plaque-forming unit (PFU) per mL followed by 1 x 107 PFU per mL every 2 weeks for a maximum of 8 cycles;
        • Each dose at most 10 mL;
• 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: 6 months
• Continued Therapy*
  *Criteria will mirror the clinical information from the prescribing information once FDA-approved
  • Cutaneous Melanoma (must meet all):
    • Currently receiving medication via Centene benefit, or documentation supports that member is currently receiving RP1 for a covered indication and has received this medication for at least 30 days;
    • Member is responding positively to therapy;
    • Maximum duration of therapy does not exceed 8 cycles;
    • Request meets one of the following:*
      • New dose does not exceed both of the following:*
        • 1 x 107 PFU per mL every 2 weeks for a maximum of 8 cycles;
        • Each dose at most 10 mL;
    • 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: 6 months

Sibeprenlimab-szsi (Voyxact) (CP.PHAR.775)

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
  • Immunoglobulin A Nephropathy (IgAN) (must meet all):
    • Diagnosis of IgAN confirmed via kidney biopsy;
    • Prescribed by or in consultation with a nephrologist;
    • Age at least 18 years;
    • Documentation of both of the following:
      • Proteinuria of at least 1 g/day or urine protein-to-creatinine ratio (UPCR) at least 0.75 g/g;
      • Estimated glomerular filtration rate (eGFR) at least 30 mL/min/1.73 m2 ;
    • Member meets both of the following, unless contraindicated or clinically significant adverse effects are experienced:*
      • Failure of a renin-angiotensin-aldosterone system (RAAS) inhibitor (e.g., irbesartan, losartan, lisinopril, benazepril) for at least 12 weeks;
      • RAAS inhibitor therapy dose was at least 50% of maximum labeled dose;
    • Failure of a sodium-glucose cotransporter-2 (SGLT2) inhibitor (e.g., empagliflozin, dapagliflozin) at up to maximally indicated doses, unless clinically significant adverse effects are experienced or all are contraindicated;*
    • Failure of Filspari® or Vanrafia™ at up to maximally indicated doses, unless clinically significant adverse effects are experienced or both are contraindicated;*
    • Dose does not exceed both of the following:
      • 400 mg every 4 weeks;
      • 1 prefilled syringe per 4 weeks.
  • Approval duration: 6 months
• Continued Therapy
  • Immunoglobulin A Nephropathy (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 one of the following:
      • Decrease in UPCR from baseline;
      • Reduction of proteinuria as evidence by a lower total urine protein per day from baseline;
    • If request is for a dose increase, new dose does not exceed both of the following:
      • 400 mg every 4 weeks;
      • 1 prefilled syringe per 4 weeks.
  • Approval duration: 12 months

Gefurulimab (ALXN1720) (CP.PHAR.776)

Ambetter

Policy includes:

• Criteria will mirror the clinical information from the prescribing information once FDA-approved
• 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*
  *Criteria will mirror the clinical information from the prescribing information once FDA-approved
  • Generalized Myasthenia Gravis (gMG) (must meet all):
    • Diagnosis of gMG;*
    • Prescribed by or in consultation with a neurologist;
    • Age at least 18 years;
    • Myasthenia Gravis-Activities of Daily Living (MG-ADL) score at least 5 at baseline;*
    • Myasthenia Gravis Foundation of America (MGFA) clinical classification of Class II to IV;*
    • Member has positive serologic test for anti-AChR antibodies;*
    • Failure of a corticosteroid, unless contraindicated or clinically significant adverse effects are experienced;*
    • Failure of a cholinesterase inhibitor, unless contraindicated or clinically significant adverse effects are experienced;*
    • Failure of at least one non-steroidal immunosuppressive therapy, unless clinically significant adverse effects are experienced or all are contraindicated;*
    • ALXN1720 is not prescribed concurrently with Imaavy™, Soliris®/Bkemv™/ Epysqli®, Ultomiris®, Rystiggo®, Vyvgart®, Vyvgart® Hytrulo, or Zilbrysq®;
    • Documentation of member’s current weight in kg;*
    • Dose does not exceed the FDA approved maximum.*
    • Approval duration: Medicaid/HIM – 12 months
• Continued Therapy*
  *Criteria will mirror the clinical information from the prescribing information once FDA-approved
  • Generalized Myasthenia Gravis (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 a at least 2-point reduction from baseline in the MG-ADL total score;*
    • ALXN1720 is not prescribed concurrently with Imaavy, Soliris/Bkemv/Epysqli, Ultomiris, Rystiggo, Vyvgart, Vyvgart Hytrulo, or Zilbrysq;
    • Documentation of member’s current weight in kg;*
    • If request is for a dose increase, new dose does not exceed the FDA approved maximum.*
  • Approval duration: 12 months

Pitolisant (Wakix) (CP.PMN.221)

Ambetter

Policy updates include:

• For narcolepsy with cataplexy, revised age and dosing to allow use in patients 6 years of age and older per updated prescribing information

Budesonide (Eohilia, Uceris) (CP.PMN.294)

Ambetter

Policy updates include:

• For eosinophilic esophagitis, revised quantity limit from 20 ml to 2 packets to better reflect product availability and incorporated existing approval duration into criteria by adding requirement that requested duration of treatment does not exceed 12 weeks

Tirzepatide (Zepbound) (CP.PMN.298)

Ambetter

Policy updates include:

• Revised language for members with concurrent type 2 diabetes mellitus language from "failure" to "member has received optimal diabetic standard of care therapy as evidenced by a trial" to align with drug class
• Modified preferred liraglutide product to state ‘liraglutide (generic Victoza);’ for obstructive sleep apnea continued therapy, clarified “physician directed” weight loss program
• Added new multi-dose vial dosage form and new kwikpen dosage form

Suzetrigine (Journavx) (CP.PMN.301)

Ambetter

Policy updates include:

• Updated Food and Drug Administration (FDA) approved indication to include postoperative pain

Tradipitant (Nereus) (CP.PMN.307)

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
  • Motion Sickness Prevention (must meet all):
    • Prescribed for the prevention of motion-induced vomiting;
    • Age at least 18 years;
    • Member has a planned event expected to cause vomiting induced by motion;
    • Failure of transdermal scopolamine, unless contraindicated or clinically significant adverse effects are experienced;*
    • Failure of at least 2 antihistamines used for motion sickness (e.g., dimenhydrinate, meclizine, promethazine), unless clinically significant adverse effects are experienced or all are contraindicated;*
    • Request is for at most 7 days supply, unless medical justification is provided;
    • Request is for at most 90 doses per 365-day period, unless medical justification is provided;
    • Dose does not exceed 170 mg (2 capsules) per 24-hour period.
  • Approval duration: 7 days
• Continued Therapy
  • Motion Sickness Prevention
    • Re-authorization is not permitted. Members must meet the initial approval criteria.
  • Approval duration: Not applicable

Immune Globulins (HIM.PA.178)

Ambetter

Policy updates include:

• For Chimeric Antigen Receptor (CAR)-T cell-related toxicities, added use for acute inflammatory demyelinating polyneuropathy-type picture or bilateral facial palsy per National Comprehensive Cancer Network (NCCN)
• Added off-label indications for immune checkpoint inhibitor-related toxicities, Langerhans cell histiocytosis (LCH)- associated abnormal, heparin-induced thrombocytopenia, and pediatric acute lymphoblastic leukemia per National Comprehensive Cancer Network (NCCN)
• Added HCPCS code [J1553]

Biologic and Non-biologic DMARDs (HIM.PA.SP60)

Ambetter

Policy updates include:

• Added newly approved autoinjector formulation for Pyzchiva
• Added newly approved single-dose vial for subcutaneous injection for Selarsdi
• Applied Idacio’s pediatric age extensions for hidradenitis suppurativa and uveitis

Dupilumab (Dupixent) (HIM.PA.SP69)

Ambetter

Policy updates include:

• Added new indication for allergic fungal rhinosinusitis

Paclitaxel Protein-Bound (Abraxane) (CP.PHAR.176)

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

Policy updates include:

• Clarified off-label National Comprehensive Cancer Network (NCCN) supported indications for Kaposi sarcoma, cervical cancer, endometrial carcinoma, cutaneous melanoma, and vaginal cancer, that Abraxane is prescribed as second-line or subsequent therapy per National Comprehensive Cancer Network (NCCN)
• For Kaposi sarcoma, removed requirement of human immunodeficiency virus related and added member is paclitaxel intolerant per National Comprehensive Cancer Network (NCCN)
• Clarified endometrial carcinoma as recurrent disease and melanoma as metastatic or unresectable disease per National Comprehensive Cancer Network (NCCN)
• For all indications for Medicaid and Ambetter, extended initial approval duration from 6 to 12 months

Ado-Trastuzumab Emtansine (Kadcyla) (CP.PHAR.229)

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

Policy updates include:

• Added off-label indication for brain metastases in HER2 positive breast cancer per National Comprehensive Cancer Network (NCCN)
• For non-small cell lung cancer, added criteria prescribed as subsequent therapy per National Comprehensive Cancer Network (NCCN)
• For all indications for Medicaid and Ambetter, extended initial approval duration from 6 to 12 months

Mitoxantrone (CP.PHAR.258)

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

Policy updates include:

• For pediatric BCR::ABL1-negative B- acute lymphoblastic leukemia, added requirement for use as a component of UKALL R3 or COG AALL 1331 per National Comprehensive Cancer Network (NCCN)
• Removed B-cell lymphomas as coverable diagnoses as National Comprehensive Cancer Network (NCCN) no longer recommends these uses
• For Medicaid and Ambetter for all indications, extended initial approval duration from 6 to 12 months for this maintenance medication for a chronic condition

Osimertinib (Tagrisso) (CP.PHAR.294)

Ambetter

Policy updates include:

• Per National Comprehensive Cancer Network (NCCN): added requirement for single agent therapy, added options for previous adjuvant chemoradiation and previous neoadjuvant Tagrisso, and removed “completely” as a qualifier for “resected”
• Revised initial approval duration for Medicaid/Ambetter to 12 months

Siponimod (Mayzent) (CP.PHAR.427)

Ambetter

Policy updates include:

• Extended initial approval duration from 6 to 12 months for this maintenance medication for a chronic condition
• Added primary progressive multiple sclerosis to section III to align with other multiple sclerosis agents

Sapropterin Dihydrochloride (Kuvan, Javygtor) (CP.PHAR.43)

Ambetter

Policy updates include:

• Added requirement for a redirection from Zelvysia (another branded generic) to unbranded generic sapropterin
• Added endocrinologist as a possible specialist to align with the Palynziq and Sephience criteria
• Added adherence to Phe-restricted diet per plan feedback and align with Sephience criteria

Narsoplimab (Yartemlea) (CP.PHAR.527)

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

Policy updates include:

• In initial therapy, added criterion that maximum duration of therapy doesn’t exceed 16 weeks for review of new members already started on Yartemlea therapy

Pacritinib (Vonjo) (CP.PHAR.583)

Ambetter

Policy updates include:

• For National Comprehensive Cancer Network (NCCN) compendium indications per National Comprehensive Cancer Network (NCCN) 2A recommendation, added criteria for myeloid/lymphoid neoplasms with eosinophilia and JAK2 rearrangement, added criteria for myeloproliferative neoplasms
• For all indications, extended initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition

Ublituximab-xiiy (Briumvi) (CP.PHAR.621)

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

Policy updates include:

• For Medicaid and Ambetter, extended initial approval duration from 6 to 12 months for this maintenance medication for a chronic condition
• Added primary progressive multiple sclerosis to section III to align with other multiple sclerosis agents

Sorafenib (Nexavar) (CP.PHAR.69)

Ambetter

Policy updates include:

• For differentiated thyroid carcinoma, modified requirement for radioactive iodine-refractory disease to apply only to papillary and follicular carcinomas per National Comprehensive Cancer Network (NCCN)
• For gastrointestinal stromal tumors, added disease qualifiers along with requirement that disease is imatinib-sensitive KIT or PDGFRA mutant per National Comprehensive Cancer Network (NCCN)
• For Medicaid and Ambetter, extended initial approval duration from 6 to 12 months

Nipocalimab-aahu (Imaavy) (CP.PHAR.720)

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

Policy updates include:

• Clarified that the required immunosuppressive therapy should be non-steroidal
• Modified initial approval duration from 6 months to 12 months for medicaid/ambetter as generalized myasthenia gravis is a chronic condition

Sunitinib (Sutent) (CP.PHAR.73)

Ambetter

Policy updates include:

• Per National Comprehensive Cancer Network (NCCN), revised the following – for gastrointestinal stromal tumor, added requirement that disease is imatinib-sensitive KIT or PDGFRA mutant, added additional disease qualifier of gross residual (R2 resection) for combination therapy, and replaced requirement for use of Sprycel with Sutent prior to Sutent+everolimus combination therapy
• For chordoma, thymic carcinoma, and soft tissue sarcoma, specified use a single agent
• For differentiated thyroid carcinoma, modified requirement for radioactive iodine-refractory disease to apply only to papillary and follicular carcinomas
• Added off-label uses of meningioma and dedifferentiated chondrosarcoma
• For Medicaid and Ambetter, extended initial approval duration from 6 to 12 months

Tetrabenazine (Xenazine) (CP.PHAR.92)

Ambetter

Policy updates include:

• Added Ingrezza Sprinkle to the concurrent use exclusion
• revised initial approval durations from 6 to 12 months for Medicaid/Ambetter

Emtricitabine/Tenofovir Alafenamide (Descovy) (CP.PMN.235)

Ambetter

Policy updates include:

• For pre-exposure prophylaxis, added requirement that Descovy is not prescribed concurrently with any other antiretroviral medications for pre-exposure prophylaxis

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

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

Policy updates include:

• For pre-exposure prophylaxis, added requirement that Apretude is not prescribed concurrently with any other antiretroviral medications for pre-exposure prophylaxis

Adrabetadex (VTS-270) (CP.PHAR.777)

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

Policy includes:

• Criteria will mirror the clinical information from the prescribing information once FDA-approved
• Criteria is only applicable for Medicaid and CHIP when the drug is added to the medical benefit for coverage
• 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, and CP.PMN.53 for Medicaid and CHIP
• Initial Approval Criteria: Niemann-Pick Disease Type C (NPC)(must meet all): *
  *Criteria will mirror the clinical information from the prescribing information once FDA-approved
  • Diagnosis of NPC confirmed by one of the following:
    • Genetic analysis indicating mutation in both alleles of NPC1 or NPC2;
    • Genetic analysis indicating mutation in one allele of NPC1 or NPC2 along with one of the following:
      • Positive filipin staining test result;
      • Positive biomarker result (e.g., oxysterol, lyso-sphingolipid, bile acid);
  • Prescribed by or in consultation with a geneticist, neurologist, endocrinologist, or metabolic disease specialist;
  • Member presents with both of the following:*
    • At least one neurological sign or symptom of the disease;
    • Neurological sign/symptom onset less than 6 years of age (i.e., infantile-onset);
  • Adrabetadex is not prescribed concurrently with Aqneursa^™ or Miplyffa^™;*
  • Dose does not exceed 900 mg intrathecally every 2 weeks.*
  • Approval duration: 12 months
• Continued Therapy: Niemann-Pick Disease Type C (must meet all): *
  *Criteria will mirror the clinical information from the prescribing information once FDA-approved
  • 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 an improvement, stabilization, or slowed disease progression in a domain affected by NPC (e.g., ambulation, fine motor skills, swallowing, sitting, speech);*
  • Adrabetadex is not prescribed concurrently with Aqneursa or Miplyffa;*
  • If request is for a dose increase, new dose does not exceed 900 mg intrathecally every 2 weeks.*
  • Approval duration: 12 months

Garetosmab (REGN2477) (CP.PHAR.778)

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

Policy includes:

• Criteria will mirror the clinical information from the prescribing information once FDA-approved
• Criteria is only applicable for Medicaid and CHIP when the drug is added to the medical benefit for coverage
• 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, and CP.PMN.53 for Medicaid and CHIP
• Initial Approval Criteria: Fibrodysplasia Ossificans Progressiva (FOP) (must meet all): *
  *Criteria will mirror the clinical information from the prescribing information once FDA-approved
  • Diagnosis of FOP;*
  • Prescribed by or in consultation with an orthopedics, orthopedic surgery, rheumatology, endocrinology, or metabolic disease specialist;
  • Age at least 18 years;*
  • Presence of ACVR1 FOP-causing mutation;*
  • Documentation of baseline heterotopic ossification (HO) volume assessed by low-dose whole body computed tomography (WBCT) scan, excluding the head;*
  • Member has a cumulative analog joint involvement scale (CAJIS) score at most 19 prior to treatment with REGN2477 (see Appendix E);*
  • Failure of both of the following at up to maximally indicated doses, unless clinically significant adverse effects are experienced or all are contraindicated:*
  • Prednisone used for flare-ups;
  • Two nonsteroidal anti-inflammatory drugs (NSAIDs) between flare-ups;
  • REGN2477 is not prescribed concurrently with Sohonos^™;
  • Dose does not exceed FDA-labeled maximum dose.*
  • Approval duration: 6 months
• Continued Therapy: Fibrodysplasia Ossificans Progressiva (must meet all): *
  *Criteria will mirror the clinical information from the prescribing information once FDA-approved
  • 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 one of the following:*
    • Reduction in flare-ups from baseline;
    • Improvement in annualized new HO volume as assessed by low-dose WBCT scan;
    • Increased or stabilized mobility;
  • REGN2477 is not prescribed concurrently with Sohonos;
  • If request is for a dose increase, new dose does not exceed the FDA-labeled maximum dose.*
  • Approval duration: 12 months

Imlifidase (IdeS) (CP.PHAR.779 )

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

Policy includes:

• Criteria will mirror the clinical information from the prescribing information once FDA-approved
• Criteria is only applicable for Medicaid and CHIP when the drug is added to the medical benefit for coverage
• 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, and CP.PMN.53 for Medicaid and CHIP
• Initial Approval Criteria: Desensitization for Kidney Transplantation (must meet all): *
  *Criteria will mirror the clinical information from the prescribing information once FDA-approved
  • Diagnosis of chronic kidney disease stage 5;
  • One of the following:*
    • Member is active on the Organ Procurement & Transplantation Network (OPTN) waiting list for a deceased donor kidney transplant;
    • Member is currently scheduled to receive a deceased donor kidney transplant;
  • Prescribed by or in consultation with a transplant specialist;
  • Age at least 18 years;*
  • Member is highly sensitized as evidenced by calculated panel reactive antibody (cPRA) at least 99.9%;*
  • Prescribed as a single agent for desensitization (i.e., IdeS will not be used concurrently with other desensitization therapies [e.g., plasma exchange, intravenous immunoglobulin, rituximab]) (note: induction and maintenance immunosuppression therapies are allowed);*
  • Member has not previously received IdeS;*
  • Request does not exceed both of the following:*
    • 0.25 mg/kg per dose;
    • A total of 2 doses.
  • Approval duration: 12 months (up to a total of 2 doses)
• Continued Therapy: Desensitization for Kidney Transplantation *
  *Criteria will mirror the clinical information from the prescribing information once FDA-approved
  • Re-authorization is not permitted
  • Approval duration: Not applicable

Isaralgagene Civaparvovec (ST-920) (CP.PHAR.780)

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

Policy includes:

• Criteria will mirror the clinical information from the prescribing information once FDA-approved
• Criteria is only applicable for Medicaid and CHIP when the drug is added to the medical benefit for coverage
• 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, and CP.PMN.53 for Medicaid and CHIP
• Initial Approval Criteria: Fabry Disease (must meet all): *
  *Criteria will mirror the clinical information from the prescribing information once FDA-approved
  • Diagnosis of Fabry disease by genetic confirmation of a mutation in the GLA gene and one of the following:*
    • Presence of a GLA pathogenic variant;
    • Presence of a GLA variant of unknown significance, and one of the following:
      • Enzyme assay demonstrating a deficiency of alpha-galactosidase A activity;
      • Family history of Fabry disease;
  • Prescribed by or in consultation with a clinical geneticist, cardiologist, nephrologist, neurologist, lysosomal disease specialist, or Fabry disease specialist;
  • Age at least 18 years;*
  • Member has at least 1 symptom characteristic of Fabry disease (e.g., cornea verticillata, acroparesthesia, anhidrosis, angiokeratoma);*
  • Member does not have any the following:*
    • Significant liver disease (e.g., clinically significant steatosis, fibrosis, metabolic dysfunction-associated steatohepatitis [MASH], cirrhosis, biliary disease, active hepatitis);
    • Heart failure with New York Heart Association (NYHA) classification at least Class III;
    • Estimated glomerular filtration rate (eGFR) less than 40 ml/min/1.73 m²;
  • Member has not received previous gene therapy;*
  • Member does not have detectable neutralizing antibodies to AAV6;*
  • Dose does not exceed a single infusion of 2.63 x 10¹³ vector genomes (vg) per kg.*
  • Approval duration: 3 months (one time infusion per lifetime)
• Continued Therapy: Fabry Disease*
  *Criteria will mirror the clinical information from the prescribing information once FDA-approved
  • Continued therapy will not be authorized as ST-920 is indicated to be dosed one time only.
  • Approval duration: Not applicable

Difamilast (Adquey) (CP.PMN.308)

Ambetter/ICHRA

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: Atopic Dermatitis (must meet all):
  • Diagnosis of atopic dermatitis;
  • Age at least 2 years;
  • Failure of a 2-week trial of two generic medium to very high potency topical corticosteroids of different molecular identities, unless contraindicated (e.g., areas involving the face, neck, or intertriginous areas) or clinically significant adverse effects are experienced;^
  • Failure of a 2-week trial of topical tacrolimus, unless contraindicated or clinically significant adverse effects are experienced;^*
  • *Prior authorization may be required for topical tacrolimus
  • Dose does not exceed 60 grams per 30 days.
  • Approval duration:  12 months
• Continued Therapy: Atopic Dermatitis (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;
  • If request is for a dose increase, new dose does not exceed 60 grams per 30 days.
  • Approval duration: 12 months

Insulin Icodec-abae (Awiqli) (CP.PMN.309)

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

Policy includes:

• Criteria is only applicable for Medicaid and CHIP when the drug is added to the medical benefit for coverage
• Requests for indications not approved by the FDA are reviewed with the off-label use policy for the relevant line of business:  CP.PMN.53 for Medicaid and CHIP
• Initial Approval Criteria: Type 2 Diabetes Mellitus (must meet all):
  • Diagnosis of type 2 diabetes mellitus;
  • Age at least 18 years;
  • Failure of a preferred long-acting human insulin analog, unless clinically significant adverse effects are experienced or all are contraindicated.
  • Approval duration: 12 months
• Continued Therapy: Type 2 Diabetes Mellitus (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;
  • Failure of a preferred long-acting human insulin analog, unless clinically significant adverse effects are experienced or all are contraindicated.
  • Approval duration: 12 months

Insulin Icodec-abae (Awiqli) (HIM.PA.180)

Ambetter/ICHRA

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: Type 2 Diabetes Mellitus (must meet all):
  • Diagnosis of type 2 diabetes mellitus;
  • Age at least 18 years;
  • Failure of both of the following, unless clinically significant adverse effects are experienced are both are contraindicated:*
    • Insulin glargine-ygfn (unbranded Semglee^®);
    • Branded Tresiba^® (insulin degludec).
  • Approval duration: 12 months
• Continued Therapy: Type 2 Diabetes Mellitus (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;
  • Failure of both of the following, unless clinically significant adverse effects are experienced are both are contraindicated:*
    • Insulin glargine-ygfn (unbranded Semglee);
    • Branded Tresiba (insulin degludec).
  • Approval duration: 12 months

Marnetegragene autotemcel (Kresladi) (CP.PHAR.599)

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

Policy updates include:

• Criteria updated per FDA labeling: removed minimum age requirement, removed option for those with an HLA-matched sibling donor, and updated dose requirement

Relacorilant (Lifyorli) (CP.PHAR.736)

Ambetter/ICHRA

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: Epithelial Ovarian, Fallopian Tube, or Primary Peritoneal Cancer (must meet all):
  • Diagnosis of epithelial ovarian, fallopian tube, or primary peritoneal cancer;
  • Prescribed by or in consultation with an oncologist;
  • Age at least 18 years;
  • Disease is platinum-resistant (i.e., disease progressed less than 6 months from completion of a platinum-containing therapy);
  • Member has received 1 to 3 prior systemic treatment regimens, at least one of which included bevacizumab (see Appendix B for examples);
  • Lifyorli is not prescribed concurrently with systemic glucocorticoids used for a lifesaving indication (e.g., immunosuppression after organ transplantation);
  • Prescribed in combination with nab-paclitaxel;
  • Request does not exceed any of the following:
    • 150 mg on the day before, the day of, and the day after each nab-paclitaxel infusion;
    • 3 capsules per dose;
    • 9 doses per 28 days;
  • Dose is at least 125 mg per dose.
  • Approval duration: 12 months
• Continued Therapy: Epithelial Ovarian, Fallopian Tube, or Primary Peritoneal Cancer (must meet all):
  • Currently receiving medication via Centene benefit, or documentation supports that member is currently receiving Lifyorli for a covered indication and has received this medication for at least 30 days;
  • Member is responding positively to therapy;
  • Prescribed in combination with nab-paclitaxel;
  • If request is for a dose increase, request does not exceed any of the following:
    • 150 mg on the day before, the day of, and the day after each nab-paclitaxel infusion;
    • 3 capsules per dose;
    • 9 doses per 28 days;
  • Dose is at least 125 mg per dose.
  • Approval duration: 12 months

Navepegritide (Yuviwel) (CP.PHAR.746)

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

Policy updates include:

• Criteria updated per prescribing information to include weight-based dosing and quantity limits
• Added to continued therapy requirement that Yuviwel is not prescribed concurrently with Voxzogo and any human growth hormone products

Biologic and Non-biologic DMARDs (HIM.PA.SP60)

Ambetter/ICHRA

Policy updates include:

• Added newly approved autoinjector formulation for Pyzchiva
• Added newly approved single-dose vial for subcutaneous injection for Selarsdi
• Applied Idacio’s pediatric age extensions for hidradenitis suppurativa and uveitis
• For Sotyktu, added newly approved psoriatic arthritis indication
• Added Sotyktu to Appendix C for contraindications/boxed warnings section
• For Cosentyx, added newly approved hidradenitis suppurativa pediatric extension for ages at least 12 years.
• Added Otezla XR to description section and list of agents in “medically necessary when the following criteria are met” statement.

Diclofenac (Cambia, Flector, Licart, Pennsaid, Zipsor, Zorvolex) (CP.PCH.28)

Ambetter

Policy updates include:

• Updated Licart indication to include pediatric patients at least 6 years old

Pembrolizumab, Pembrolizumab Berahyaluronidase alfa-pmph (Keytruda, Keytruda Qlex) (CP.PHAR.322)

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

Policy updates include:

• Updated Food and Drug Administration (FDA) Approved Indication section with addition of Food and Drug Administration (FDA)-approved test for esophageal or GEJ cancer whose tumors express PD-L1 (combined positive score (CPS) at least 1)
• For Keytruda Qlex, added indication for usage in the neoadjuvant/adjuvant setting for locally advanced head and neck squamous cell carcinoma

Teplizumab-mzwv (Tzield) (CP.PHAR.492)

Ambetter

Policy updates include:

• Revised age requirement from at least 8 years to at least 1 year to reflect pediatric extension and added new boxed warning (viral reactivation)

Anifrolumab-fnia (Saphnelo) (CP.PHAR.551)

Ambetter

Policy updates include:

• Added new subcutaneous formulations of prefilled syringe and autoinjector

Faricimab (Vabysmo) (CP.PHAR.581)

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

Policy updates include:

• For retinal vein occlusion, removed the 6-month total treatment duration restriction and added continued therapy criteria allowing re-authorization

Tividenofusp Alfa (Avlayah) (CP.PHAR.748)

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

Policy includes:

• Criteria is only applicable for Medicaid and CHIP when the drug is added to the medical benefit for coverage
• 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, and CP.PMN.53 for Medicaid and CHIP
• Initial Approval Criteria: Mucopolysaccharidosis (MPS) II: Hunter Syndrome (must meet all):
  • Diagnosis of MPS II (Hunter syndrome) confirmed by one of the following:
    • Enzyme assay demonstrating a deficiency of iduronate 2-sulfatase (IDS) activity;
    • Genetic confirmation of pathogenic or likely pathogenic mutation(s) in the IDS gene;
  • Age less than 18 years at initiation of Avlayah;
  • Member’s weight meets both of the following:
    • Documentation of current weight in kg;
    • Current weight ≥ 5 kg;
  • Member does not have advanced neurological impairment (e.g., severe cognitive decline, profound functional dependence);
  • Avlayah is not prescribed concurrently with Elaprase^®;
  • Dose does not exceed 15 mg/kg per week.
  • Approval duration: 12 months
• Continued Therapy: Mucopolysaccharidosis II: Hunter 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 improvement or stabilization in the individual member’s MPS II manifestation profile;
  • Member does not have advanced neurological impairment (e.g., severe cognitive decline, profound functional dependence);
  • Avlayah is not prescribed concurrently with Elaprase;
  • Documentation of member’s current weight in kg;
  • If request is for a dose increase, new dose does not exceed 15 mg/kg per week.
  • Approval duration: 12 months

Lunsotogene parvec-cwha (Otarmeni) (CP.PHAR.757)

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

Policy includes:

• Criteria is only applicable for Medicaid and CHIP when the drug is added to the medical benefit for coverage
• 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, and CP.PMN.53 for Medicaid and CHIP

• Initial Approval Criteria: Sensorineural Hearing Loss (must meet all):
  • Diagnosis of severe-to-profound sensorineural hearing loss as evidenced by both of the following:
    • Genetic testing confirms biallelic pathogenic or likely pathogenic OTOF variants;
    • Member meets all of the following in the requested treatment ear(s):
    • Severe-to-profound hearing loss defined by an average audiometric threshold of greater than 90 dB HL;
    • Absent auditory brainstem response (ABR);
    • Intact outer hair cell function as evidenced by one of the following:
      • Presence of otoacoustic emissions (OAE);
      • Presence of a cochlear microphonic;
  • Prescribed by or in consultation with an otolaryngologist;
  • Member does not have a history of a cochlear implant in the requested treatment ear(s);
  • Member has not previously been treated with Otarmeni in the requested treatment ear(s);
  • Member has not received prior gene therapy;
  • Dose does not exceed a single intracochlear infusion of 7.2 x 10¹² vector genomes (vg) per ear.
  • Approval duration: 3 months (one lifetime intracochlear infusion per ear)
• Continued Therapy: Sensorineural Hearing Loss  
  • Re-authorization is not permitted. Members must meet the initial approval criteria.
  • Approval duration: Not applicable

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

Ambetter

Policy updates include:

• Added new Jakafi XR formulation to policy
• Removed health plan-approved quantity limit criterion

Dextromethorphan-bupropion (Auvelity) (CP.PMN.284)

Ambetter

Policy updates include:

• Added new indication for treatment of agitation associated with dementia due to Alzheimer’s disease
• Revised continued therapy criteria to allow continuity of care for major depressive disorder

Insulin Glargine (Basaglar, Langlara, Lantus/unbranded Lantus, Rezvoglar, Toujeo/unbranded Toujeo) (HIM.PA.09)

Ambetter

Policy updates include:

• Added Langlara to policy

Inhaled asthma and COPD agents (HIM.PA.153)

Ambetter

Policy updates include:

• For Symbicort Aerosphere, added new indication for asthma in patients 12 years of age and older and new strength of 80 mcg budesonide per updated prescribing information

GLP-1 receptor agonists (HIM.PA.53)

Ambetter

Policy updates include:

• Revised “Rybelsus formulation R2” to “Ozempic tablets” per manufacturer rebranding and clarified Ozempic tablets vs injection where applicable
• Added new dosage form of single-dose prefilled syringes for Ozempic injection