Effective November 1, 2026: Pharmacy and Biopharmacy Policies

Policy

Applicable Products

New Policy Overview or Updated Policy Revisions

Ferric Carboxymaltose (Injectafer) (CP.PHAR.234)

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

Added redirection to generic for brand requests PER SDC request; added ICHRA line of business

Emicizumab-kxwh (Hemlibra) (CP.PHAR.370)

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

Removed inhibitor level criterion for hemophilia with inhibitors; added bypassing agent option to on-demand usage that may be continued for hemophilia A with inhibitors; added ICHRA line of business.

Teprotumumab (Tepezza)  (CP.PHAR.465)

Ambetter, Ambetter Health

Added requirement that Tepezza is not prescribed concurrently with Lumvoa and member has not previously received Lumvoa; added ICHRA line of business.

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

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

Removed inhibitor level criterion for hemophilia with inhibitors; revised provider confirmation of discontinuation of prophylaxis to exclusion for concurrent use of hemophilia prophylaxis agents with examples of allowable agents for on-demand usage; added ICHRA line of business.

Fitusiran (Qfitlia) (CP.PHAR.706)

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

Added Hemlibra redirection for hemophilia A with SDC agreement; added template language of clinically significant adverse effects or contraindication for failure of bypassing agent, FVIII product, and FIX product as prophylaxis therapy; added bypassing agent option to on-demand usage that may be continued; added ICHRA line of business.

Veligrotug (Lumvoa)  (CP.PHAR.773)

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

RT4: drug is now FDA-approved; modified to weight-based dosing per prescribing information; added requirement that member has not previously received Tepezza.

Brepocitnib (CP.PHAR.793)

Ambetter, Ambetter Health

Policy created pre-emptively.

Daraxonrasib (RMC-6236) (CP.PHAR.794)

Ambetter, Ambetter Health

Policy created pre-emptively.

Venglustat (SAR402671) (CP.PHAR.795)

Ambetter, Ambetter Health

Policy created pre-emptively.

Zilurgisertib (INCB0009258) (CP.PHAR.796)

Ambetter, Ambetter Health

Policy created pre-emptively.

Cemdisiran (ALN-CC5) (CP.PHAR.797)

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

Policy created pre-emptively.

Ribitol (BBP-418) (CP.PHAR.798)

Ambetter, Ambetter Health

Policy created pre-emptively.

Suzetrigine (Journavx) (CP.PMN.301)

Ambetter, Ambetter Health

Clarified failure of at least two analgesic medications to be within the last 30 days; added Journavx has not been prescribed within the last 30 days, or member is experiencing a new episode of moderate to severe acute pain; added tablet quantity limit of 29 tablets per 14 days per course of treatment; added total treatment duration of 14 days.

Ensitrelvir (Xocova)  (CP.PMN.311)

Ambetter, Ambetter Health

Policy created.

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

Ambetter

RT4: added newly FDA-approved Icotyde for PsO; for PsO: for Taltz and Icotyde pediatric redirection; updated criteria from “failure of TWO” to “failure of THREE” to align with redirection to Enbrel and Otezla as alternative option with “or” instead of “and” rationale; RT4: for Cosentyx, updated AS criteria with pediatric extension for ages 12 years and older per prescribing information; RT4: for Stelara/ustekinumab, updated CD criteria with pediatric extension for ages 2 to 17 years per prescribing information; 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 HS, UC, UV, and continued therapy “All Other Indications In Section I”, added bypass of “FDA-approved age limit does not overlap” for preferred adalimumab biosimilar requirement; RT4: added FDA approved biosimilars Immgolis and Immgolis Intri to criteria; for RA for Simponi, Simponi Aria, Immgolis, and Immgolis Intri, added requirement for concomitant use with MTX or another DMARD; added HCPCS code Q5164.
RT4: for Tofidence, added newly approved CRS indication to criteria; 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 “up to 4 doses total” for clarity and to align with Commercial and Medicaid; RT4: for Skyrizi, added newly approved pediatric extension for PsO and added redirection to Skyrizi for PsO pediatric ages; added new 55 mg/0.37 mL single-dose prefilled syringe dosage strength; RT4: for Skyrizi, added newly approved pediatric extension for PsA and added redirection to Skyrizi for PsA pediatric ages; for pJIA, removed Xeljanz XR; for PsO, added Tremfya requirement for initiating Stelara therapy for ages 6 to 17 years criteria to reflect pediatric extension; for PsA, added Tremfya and tofacitinib (generic Xeljanz) as requirement for initiating Stelara therapy for ages 6 to 17 years criteria to reflect pediatric extension. Per SDC: for RA, PsA, AS, pJIA, and UC, removed criteria requiring use of brand Xeljanz/Xeljanz XR and added criteria requiring use of tofacitinib/tofacitinib XR (generic Xeljanz/Xeljanz XR); added generic redirection to tofacitinib/tofacitinib XR for brand Xeljanz/Xeljanz XR requests.

Benralizumab (Fasenra) (HIM.PA.SP70)

Ambetter, Ambetter Health

RT4: added criteria for newly approved indication of HES;
added ICHRA line of business.

Fidanacogene Elaparvovec-dzkt (Beqvez) (CP.PHAR.643)

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

Retire, no longer commercialized.

Valoctocogene Roxaparvovec-rvox (Roctavian) (CP.PHAR.466)

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

Retire, no longer commercialized.