Effective August 1, 2026: Pharmacy and Biopharmacy Policies

Policy

Applicable Products

New Policy Overview or Updated Policy Revisions

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

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

Added Ranluspec to policy.

IncobotulinumtoxinA (Xeomin) (CP.PHAR.231)

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

Updated FDA approved indications to include coverage of pediatric patients for upper limb spasticity without regard for cerebral palsy etiology per PI.

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

Ambetter/ Ambetter Health Solutions

Drug is now FDA approved for recently diagnosed Stage 3 T1D – updated criteria per FDA labeling: added upper age limit of 17 years and revised definition of recently diagnosed from 6 to 8 weeks; added new contraindication to Appendix C; added ICHRA line of business; references reviewed and updated.

Capivasertib (Truqap) (CP.PHAR.663)

Ambetter/ Ambetter Health Solutions

Added criteria for the newly approved prostate cancer indication; added ICHRA line of business.

Afamitresgene Autoleucel (Tecelra) (CP.PHAR.678)

Ambetter

Added pediatric extension down to 12 years of age and removed accelerated approval language per updated prescribing information.

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

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

Updated FDA approved indications to include additional use in adult patients with unresectable or metastatic TNBC who are not candidates for PD-1/PD-L1 inhibitor therapy; updated requirements for TNBC to allow use in PD-L1 negative tumors, and for PD-L1 positive tumors removed requirements for Combined Positive Score < 10 and disease is negative for germline BRCA 1/2 pathogenic variant and instead require provider attestation that member is ineligible for PD-1/PD-L1 inhibitor treatment.