Effective November 1, 2026: Pharmacy and Biopharmacy Policies

Policy

Applicable Products

New Policy Overview or Updated Policy Revisions

Cabozantinib (Cabometyx, Cometriq, Omcazio) (CP.PHAR.111)

Ambetter/Ambetter Health

RT4: added new capsule formulation Omcazio; added ICHRA line of business.

Infusion Site of Care Optimization (CP.PHAR.493)

Ambetter

Updated to include AR Exchange line of business effective 1/1/2027 and KS, MO, and TX Exchange lines of business effective 11/1/2026.

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

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

RT4: added new FDA-approved indication of essential thrombocythemia and removed it from NCCN Recommended Uses (off-label) section; for essential thrombocythemia, added requirement for prior cytoreductive therapy per NCCN and pivotal study design as an alternative option to the requirement for use as a substitute for peginterferon alfa-2a; added ICHRA line of business.

Lenacapavir (Sunlenca, Yeztugo) (CP.PHAR.622)

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

RT4: added newly approved indication and corresponding criteria for oral loading as component of the initiation regimen for Bixlenvo for HIV-1 infection.

Tislelizumab-jsgr (Tevimbra) (CP.PHAR.687)

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

RT4: updated criteria to include new indication in combination with zanidatamab-hrii and chemotherapy for first-line HER2+ G/GEJ or esophageal adenocarcinoma per updated PI.

Zanidatamab-hrii (Ziihera) (CP.PHAR.709)

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

RT4: updated criteria to include new indications in combination with fluoropyrimidine- and platinum-containing chemotherapy ± tislelizumab-jsgr for first-line HER2+ gastric, gastroesophageal junction, or esophageal adenocarcinoma per updated PI; added ICHRA line of business.

Sevabertinib (Hyrnuo) (CP.PHAR.764)

Ambetter

RT4: revised criteria to reflect updated FDA-approved indication for use as first-line therapy for NSCLC.

Garetosmab (Pasatru) (CP.PHAR.778)

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

Drug is now FDA approved – criteria updated per FDA labeling: added requirement for documentation of baseline HO lesion count; added medical genetics to list of provider specialty options; revised initial 6-month approval duration to 12 months for Medicaid/HIM/ICHRA lines of business and to “6 months or to the member’s renewal date, whichever is longer” for Commercial line of business; added requirement for member’s body weight for both initial and continued therapy sections; for continued therapy positive response criteria, clarified that “improvement” is “reduction” in annualized new HO volume and added option of reduction in new HO lesions as assessed by low-dose WBCT scan; references reviewed and updated.

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

Ambetter/Ambetter Health

Added brand Victoza to Section I.B as agent is non-preferred; added “brand” to Victoza to clarify if requests are for brand Victoza, member must use generic liraglutide.