Effective September 1, 2026: Pharmacy and Biopharmacy Policies

Policy

Applicable Products

New Policy Overview or Updated Policy Revisions

Nilotinib (Tasigna, Cavhanza, Danziten, Nilceya) (CP.PHAR.76)

Ambetter/ Ambetter Health (Solutions)

Added newly approved Cavhanza to policy; updated Appendix D with revised language for Tennessee.

Tiopronin (Thiola, Tiocystin), Tiopronin Delayed-Release (Thiola EC, Venxxiva) (CP.PHAR.725)

Ambetter/ Ambetter Health (Solutions)

Added immediate release formulations of tiopronin (Thiola, Tiocystin) to policy; added age requirement for Venxxiva per FDA labeled indication.

Romiplostim (Nplate) (CP.PHAR.179)

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

Added to Appendix D examples of immune checkpoint inhibitor-related toxicities.

Factor VIII-von Willebrand (Alphanate, Humate-P, Vonvendi, Wilate) (CP.PHAR.216)

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

RT4: removed criterion for age ≥ 6 years for Wilate use in VWD routine prophylaxis per updated Prescribing Information; clarified Wilate for hemophilia A is FDA-indicated for pediatric patients age ≥ 12 years per updated Prescribing Information and added corresponding age criterion for hemophilia A; added Humate-P age criterion of ≥ 18 years for hemophilia A to align with the FDA-labeled indication; added ICHRA line of business.

Adalimumab (Humira) (CP.PHAR.242)

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

RT4: for Hadlima, applied pediatric age extensions for HS and UV and added new single-dose autoinjector PushTouch dosage strength [80 mg/0.8 mL]; for UC and continued therapy “All Other Indications in Section I”, removed age specifications and added bypass of “FDA-approved age limit does not overlap” for preferred biosimilar requirement.

Anakinra (Kineret) (CP.PHAR.244)

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

Per SDC: for RA, removed criteria requiring use of brand Xeljanz/Xeljanz XR and added criteria requiring use of tofacitinib/tofacitinib XR (generic Xeljanz/Xeljanz XR).

Tocilizumab (Actemra) (CP.PHAR.263)

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

RT4: for Tofidence, added newly approved CRS indication to criteria; for Tofidence and Tyenne, updated indication for COVID-19 to include pediatric extension; for CRS, revised criterion for CRS prophylaxis use to “administering T-cell engaging bispecific antibody therapy” and added option for CRS treatment related to T-cell engaging bispecific therapy per NCCN; removed criterion for “used as supportive care in severe CRS related to blinatumomab therapy” as requirement is met through criterion for CRS treatment related to T-cell engaging bispecific antibody therapy; for continued therapy, removed “CAR-T cell induced” as CRS also includes T-cell engaging bispecific antibody therapy; for CRS initial approval criteria and continued therapy, added 3 month duration to align with HIM duration extension. Per SDC: for pJIA, and RA, removed criteria requiring use of brand Xeljanz/Xeljanz XR and added criteria requiring use of tofacitinib/tofacitinib XR (generic Xeljanz/Xeljanz XR).

Ipilimumab (Yervoy) (CP.PHAR.319)

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

RT4: updated FDA approved indication for MSI-H/dMMR CRC with the requirement for an FDA-approved diagnostic test.

Sarilumab (Kevzara) (CP.PHAR.346)

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

Per SDC: for pJIA, removed criteria requiring use of brand Xeljanz and added criteria requiring use of tofacitinib (generic Xeljanz).

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

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

RT4: added new FDA-approved indication for MIBC in combination with Keytruda or Keytruda Qlex for neoadjuvant and adjuvant treatment (regardless of cisplatin eligibility); for la/mUC, revised to allow use as single agent after one or more prior of lines of therapy and clarified use should be first-line or second-line systemic therapy when prescribed in combination with Keytruda or Keytruda Qlex per NCCN.

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

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

RT4: added new FDA-approved indications for first-line treatment of TNBC as monotherapy for those who are not candidates for PD-1 or PD-L1 inhibitor-based therapy OR in combination with pembrolizumab or pembrolizumab and berahyaluronidase alfa-pmph; for breast cancer, added additional qualifier of locally advanced per prescribing information.

Selpercatinib (Retevmo) (CP.PHAR.478)

Ambetter/Ambetter Health

RT4: converted FDA-approved indication for solid tumors from accelerated approval to full approval.

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

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

RT4: added new formulation for Sarclisa Escena for use with on-body injector or syringe and infusion set.

Belzutifan (Welireg) (CP.PHAR.553)

Ambetter

RT4: added new FDA-approved indication for combination use for adjuvant treatment of patients with ccRCC at intermediate-high or high risk of recurrence following nephrectomy, or following nephrectomy and resection of metastatic lesions.

Ropeginterferon alfa-2b-njft (Besremi) (CP.PHAR.570)

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

RT4: added new prefilled pen injector formulation; updated Appendix D with revised language for Tennessee.

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

Ambetter/Ambetter Health

RT4: updated to allow use down to 2 years of age per prescribing information pediatric extension; for SCD added requirement for weight ≥ 12 kg; added ICHRA line of business.

Furosemide (Furoscix, Lasix ONYU) (CP.PHAR.608)

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

RT4: for Furoscix, added new prefilled autoinjector dosage form, ReadyFlow.

Bimekizumab-bkzx (Bimzelx) (CP.PHAR.660)

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

Per SDC: for PsA and AS, removed criteria requiring use of brand Xeljanz/Xeljanz XR and added criteria requiring use of tofacitinib/tofacitinib XR (generic Xeljanz/Xeljanz XR).

Topical Immunomodulators (CP.PMN.107)

Ambetter/Ambetter Health

For continued therapy, corrected typo by adding “exceed” for “new dose does not exceed health plan-approved quantity limit” criterion; added ICHRA line of business.

Dextromethorphan-Quinidine (Nuedexta) (CP.PMN.93)

Ambetter/Ambetter Health

Per SDC request, for brand Nuedexta added redirection to generic; added ICHRA line of business.

Palbociclib (Ibrance) (HIM.PA.173)

Ambetter

RT4: for breast cancer, added newly approved indication for combination use with trastuzumab ± pertuzumab and endocrine therapy for HR-positive, HER2-positive disease to criteria; for soft tissue sarcoma, removed limitation that request is for capsules as tablet formulation is now supported by NCCN; added bypass to Kisqali and Verzenio redirection for HER2-positive breast cancer; updated Appendix E with revised language for Tennessee.