Policy
| Applicable Products
| New Policy Overview or Updated Policy Revisions
|
Darbepoetin Alfa (Aranesp) (CP.PHAR.236)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- For continuation of therapy request for anemia associated with chronic kidney disease, modified current hemoglobin requirement from at most 12 g/dl to at most 11.5 g/dl
- For anemia associated with chronic kidney disease, added requirement that requested product is not prescribed concurrently with a hypoxia-inducible factor prolyl hydroxylase (HIF PH) inhibitor
|
Epoetin Alfa (Epogen, Procrit), Epoetin Alfa-epbx (Retacrit) (CP.PHAR.237)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- For continuation of therapy request for anemia associated with chronic kidney disease, modified current hemoglobin requirement from at most 12 g/dl to at most 11.5 g/dl
- For anemia associated with chronic kidney disease, added requirement that requested product is not prescribed concurrently with a hypoxia-inducible factor prolyl hydroxylase (HIF PH) inhibitor
|
Methoxy Polyethylene Glycol-Epoetin Beta (Mircera) (CP.PHAR.238)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- For continuation of therapy request modified current hemoglobin requirement from at most 12 g/dl to at most 11.5 g/dl
- Added requirement that requested product is not prescribed concurrently with a hypoxia-inducible factor prolyl hydroxylase (HIF PH) inhibitor
|
Cabazitaxel (Jevtana) (CP.PHAR.316)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Per National Comprehensive Cancer Network (NCCN) compendium for off-label use in small cell/neuroendocrine prostate cancer clarified that Jevtana is prescribed in combination with carboplatin with concurrent steroid
- Revised initial approval duration for Medicaid/Ambetter from 6 to 12 months
|
Telotristat Ethyl (Xermelo) (CP.PHAR.337)
| Ambetter
| Policy updates include:
- In continued therapy, clarified examples of positive therapy
- Extended initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition
|
Abaloparatide (Tymlos) (CP.PHAR.345)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) and CHIP
| Policy updates include:
- Removed Ambetter and Commercial line of business
- Added redirection to generic teriparatide.
|
Caplacizumab-yhdp (Cablivi) (CP.PHAR.416)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- For continued criteria for new treatment cycle requests, added diagnostic requirement for confirmation of relapse
|
Ciltacabtagene Autoleucel (Carvykti) (CP.PHAR.533)
| Ambetter
| Policy updates include:
- Per National Comprehensive Cancer Network (NCCN) added additional approval pathway after at least 3 prior lines of therapy that also includes one anti-CD38 antibody
|
Vutrisiran (Amvuttra) (CP.PHAR.550)
|
| - Policy updates include:
- For diagnosis by cardiac uptake, specified radionucleotide scan should be SPECT (Single Photon Emission Computed Exercise Tomography)
- Removed Tegsedi from criteria as agent is discontinued
- For Medicaid/Ambetter revised initial approval duration from 6 to 12 months
|
Mitapivat (Pyrukynd, Aqvesme) (CP.PHAR.558)
| Ambetter
| Policy updates include:
- For beta thalassemia and Hemoglobin E/beta thalassemia, added redirection to Reblozyl for members that received at least 6 red blood cell units in the last 6 months
|
Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) (CP.PHAR.582)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) and CHIP
| Policy updates include:
- Added Erleada and Nubeqa as additional examples of androgen receptor pathway inhibitors that would qualify to satisfy prior therapy requirements
- For continuation of therapy added requirement that member continues to use a gondatropin-releasing hormone analog concurrently or has had a bilateral orchiectomy
|
Capecitabine (Xeloda) (CP.PHAR.60)
| Ambetter
| Policy updates include:
- Updated boxed warnings for patients with complete DPD deficiency and added criterion to confirm that a homozygous or compound heterozygous DPYD variant is not present, unless immediate treatment is necessary
- For off-label indications, added appendiceal neoplasms and cancers and subtypes of head and neck cancer (nasopharynx and occult primary tumor) and removed endometrial carcinoma per National Comprehensive Cancer Network (NCCN)
- Extended initial approval duration from 6 to 12 months for this maintenance medication for a chronic condition
|
Zilucoplan (Zilbrysq) (CP.PHAR.616)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Added redirection to Ultomiris.
|
Birch Triterpenes (Filsuvez) (CP.PHAR.669)
| Ambetter
| Policy updates include:
- For initial approval criteria and continued therapy, added “on the same target wound” to clarify Filsuvez is not used concurrently on the same wound as Zevaskyn and Vyjuvek
- Added no concurrent use with Zevaskyn
|
Vadadustat (Vafseo) (CP.PHAR.677)
| Ambetter
| Policy updates include:
- For continuation of therapy request modified current hemoglobin requirement from at most 12 g/dl to at most 11.5 g/dl
- Added requirement that Vafseo should not be prescribed concurrently with erythropoiesis-stimulating agent
|
Olezarsen (Tryngolza) (CP.PHAR.689)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Added option to be prescribed by gastroenterologist or pancreatologist
- Added requirement that Tryngola is not prescribed concurrently with Redemplo to prevent duplicative therapy
|
Plozasiran (Redemplo) (CP.PHAR.721)
| Ambetter
| Policy updates include:
- Added option to be prescribed by gastroenterologist or pancreatologist
- In continued therapy, added Redemplo is not prescribed concurrently with Tryngolza
|
Tiopronin Delayed-Release (Thiola EC) (CP.PHAR.725)
| Ambetter
| Policy updates include:
- Added Venxxiva as another brand formulation of Thiola EC that would require redirection to a non-brand generic equivalent
- For Continued Therapy added the same requirement for concomitant use with conventional therapies as exists in the Initial Approval section and as stated in the Food and Drug Administration (FDA)-labeled indication
|
Nerandomilast (Jascayd) (CP.PHAR.759)
| Ambetter
| Policy updates include:
- For idiopathic pulmonary fibrosis added redirection through both generic pirfenidone and Ofev
- For progressive pulmonary fibrosis added redirection through Ofev
|
Nilotinib (Tasigna, Danziten) (CP.PHAR.76)
| Ambetter
| Policy updates include:
- Added new branded product Nilceya to criteria
- Generic nilotinib is now available, so clarified generic redirection by removing ‘if available’
- For Medicaid/Ambetter revised initial approval duration from 6 to 12 months
- Extended off-label use to other nilotinib formulations
|
Thalidomide (Thalomid) (CP.PHAR.78)
| Ambetter
| Policy updates include:
- For multicentric Castleman’s disease, removed option as use in active idiopathic MCD without organ failure per National Comprehensive Cancer Network (NCCN)
- For multiple myeloma, erythema nodosum leprosum, and off-label National Comprehensive Cancer Network (NCCN) compendium indications, extended initial approval durations from 6 months to 12 months for this maintenance medication for a chronic condition
- Revised continued therapy duration for aphthous stomatitis or ulcers to 6 months
|
Hydroxyurea (Siklos, Xromi) (CP.PMN.193)
| Ambetter
| Policy updates include:
- For oncology off-label indications, added specialist requirement for an oncologist or hematologist
|
Solriamfetol (Sunosi) (CP.PMN.209)
| Ambetter
| Policy updates include:
- Added requirement for obstructive sleep apnea that Sunosi is prescribed concurrently with continued use of positive airway pressure therapy
- Revised continuous positive airway pressure requirement to allow any positive airway pressure therapy (e.g., bipap)
- For continued therapy added improvement in reported daytime wakefulness as an example of positive response to therapy
|
Armodafinil (Nuvigil) (CP.PMN.35)
| Ambetter
| Policy updates include:
- Added requirement for obstructive sleep apnea that armodafinil (Nuvigil) is prescribed concurrently with continued use of positive airway pressure therapy
- Revised continuous positive airway pressure requirement to allow any positive airway pressure therapy (e.g., bipap)
|
Modafinil (Provigil) (CP.PMN.39)
| Ambetter
| Policy updates include:
- Added requirement for obstructive sleep apnea that modafinil (Provigil) is prescribed concurrently with continued use of positive airway pressure therapy; revised continuous positive airway pressure requirement to allow any positive airway pressure therapy (e.g., bipap)
|
Sodium Oxybate (Xyrem, Lumryz) and Calcium, Magnesium, Potassium, and Sodium Oxybate (Xywav) (CP.PMN.42)
| Ambetter
| Policy updates include:
- For continued therapy added requirement for brand Xyrem requests, member must use sodium oxybate (generic Xyrem)
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