Effective December 1, 2026: Pharmacy and Biopharmacy Policies

Policy

Applicable Products

New Policy Overview or Updated Policy Revisions

Atacicept-vymj (Trutakna) (CP.PHAR.805)

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

Policy created

Camizestrant (Etcamah) (CP.PHAR.806)

Ambetter/Ambetter Health

Policy created

Enlicitide (Lipfendra) (CP.PHAR.807)

Ambetter/Ambetter Health

Policy created

Gedatolisib (Revtorpyk) (CP.PHAR.808)

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

Policy created

Iberdomide (Zenbexus) (CP.PHAR.809)

Ambetter/Ambetter Health

Policy created

Oveporexton (Orzeyful) (CP.PHAR.810)

Ambetter/Ambetter Health

Policy created

Zidesamtinib (Jideytro) (CP.PHAR.811)

Ambetter/Ambetter Health

Policy created

Centanafadine (Simtriyo) (CP.PMN.312)

Ambetter/Ambetter Health

Policy created

Tebipenem pivoxil (Utebzi) (CP.PMN.313)

Ambetter/Ambetter Health

Policy created

Pencillamine (Cuprimine) (CP.PCH.09)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; for cystinuria, removed IL HIM step therapy bypass for redirection to urinary alkalinizing agent; references reviewed and updated.

Diclofenac (Cambia, Flector, Licart, Pennsaid, Zipsor, Zorvolex) (CP.PCH.28)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Dapsone (Aczone Gel) (CP.PCH.32)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; references reviewed and updated.

Colonoscopy Preparation Products (CP.PCH.43)

Ambetter

4Q 2026 annual review: no significant changes; incorporated existing quantity limit from approval duration directly into criteria; references reviewed and updated.

Pancrelipase (Creon, Pancreaze, Pertyze, Viokace, Zenpep) (CP.PCH.44)

Ambetter

4Q 2026 annual review: no significant changes; references reviewed and updated.

Abrocitinib (Cibinqo) (CP.PCH.57)

Ambetter

4Q 2026 annual review: no significant changes; added Ebglyss and Nemluvio as examples of biologic medications for which concurrent use is excluded; references reviewed and updated.

Nemolizumab-ilto (Nemluvio) (CP.PCH.59)

Ambetter

4Q 2026 annual review: no significant changes; references reviewed and updated.

Avatrombopag (Doptelet, Doptelet Sprinkle) (CP.PHAR.130)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added BTK inhibitor for concurrent prescribing exclusion for all indications; added ICHRA line of business; references reviewed and updated.

Nitisinone (Orfadin, Nityr, Harliku) (CP.PHAR.132)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA LOB; references reviewed and updated.

Idelalisib (Zydelig) (CP.PHAR.133)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; references reviewed and updated.

Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex, Jylamvo) (CP.PHAR.134)

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

4Q 2026 annual review: no significant changes; added ICHRA line of business; updated boxed warning for Xatmep and Jylamvo per PI; references reviewed and updated.

Elagolix (Orilissa), elagolix-estradiol-norethindrone (Oriahnn) (CP.PHAR.136)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Ribavirin (CP.PHAR.141)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; removed discontinued Viekira from list of combination use drugs; added ICHRA line of business; references reviewed and updated.

Adefovir (CP.PHAR.142)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Betaine (Cystadane) (CP.PHAR.143)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; consolidated 12-month auth durations for all lines of business into one statement; added ICHRA line of business; references reviewed and updated.

Baclofen (Fleqsuvy, Gablofen, Lioresal, Lyvispah, Ozobax) (CP.PHAR.149)

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

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Levoleucovorin (Khapzory) (CP.PHAR.151)

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

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Degarelix (Firmagon) (CP.PHAR.170)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; references reviewed and updated.

Belatacept (Nulojix) (CP.PHAR.201)

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

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Irinotecan Liposome (Onivyde) (CP.PHAR.304)

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

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Elotuzumab (Empliciti) (CP.PHAR.308)

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

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Belinostat (Beleodaq) (CP.PHAR.311)

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

4Q 2026 annual review: added ICHRA line of business; references reviewed and updated.

Pralatrexate (Folotyn) (CP.PHAR.313)

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

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Necitumumab (Portrazza) (CP.PHAR.320)

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

4Q 2026 annual review: added Commercial and ICHRA lines of business; references reviewed and updated.

Ziv-aflibercept (Zaltrap) (CP.PHAR.325)

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

4Q 2026 annual review: added ICHRA line of business; references reviewed and updated.

Asfotase Alfa (Strensiq) (CP.PHAR.328)

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

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Pasireotide (Signifor, Signifor LAR) (CP.PHAR.332)

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

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Daunorubicin-cytarabine (Vyxeos) (CP.PHAR.352)

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

4Q 2026 annual review: added ICHRA line of business; references reviewed and updated.

Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas) (CP.PHAR.353)

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

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Testosterone (Testopel, testosterone undecanoate) (CP.PHAR.354)

Ambetter

4Q 2026 annual review: no significant changes; references reviewed and updated.

Gemtuzumab (Mylotarg) (CP.PHAR.358)

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

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Inotuzumab Ozogamicin (Besponsa) (CP.PHAR.359)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Pegvisomant (Somavert) (CP.PHAR.389)

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

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Cholic Acid (Cholbam) (CP.PHAR.390)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Lanreotide (Somatuline Depot) (CP.PHAR.391)

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

4Q 2026 annual review: no significant changes; added ICHRA line of business; updated Appendix E with revised language for Tennessee, references reviewed and updated.

Leucovorin Injection (CP.PHAR.393)

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

4Q 2026 annual review: no significant changes; references reviewed and updated.

Dacomitinib (Vizimpro) (CP.PHAR.399)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; references reviewed and updated.

Fremanezumab-vfrm (Ajovy) (CP.PHAR.403)

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

4Q 2026 annual review: no significant changes; references reviewed and updated.

Galcanezumab-gnlm (Emgality) (CP.PHAR.404)

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

4Q 2026 annual review: no significant changes; references reviewed and updated.

Darolutamide (Nubeqa) (CP.PHAR.435)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; references reviewed and updated.

Pexidartinib (Turalio) (CP.PHAR.436)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; references reviewed and updated.

Thioguanine (Tabloid) (CP.PHAR.437)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; consolidated all indications in one section for continued therapy; added ICHRA line of business; references reviewed and updated.

Trientine (Syprine, Cuvrior) (CP.PHAR.438)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Eptinezumab (Vyepti) (CP.PHAR.489)

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

4Q 2026 annual review: no significant changes; references reviewed and updated.

Rimegepant (Nurtec ODT) (CP.PHAR.490)

Ambetter

4Q 2026 annual review: no significant changes; references reviewed and updated.

Tafasitamab-cxix (Monjuvi) (CP.PHAR.508)

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

4Q 2026 annual review: no significant changes; for Commercial approval duration, added injectable standard language of “6 months or to the member’s renewal date, whichever is longer”; added ICHRA line of business; references reviewed and updated.

Triheptanoin (Dojolvi) (CP.PHAR.509)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Anifrolumab-fnia (Saphnelo) (CP.PHAR.551)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; added HCPCS codes; references reviewed and updated.

Belzutifan (Welireg) (CP.PHAR.553)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Elivaldogene autotemcel (Skysona) (CP.PHAR.556)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Mobocertinib (Exkivity) (CP.PHAR.559)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; references reviewed and updated.

Atogepant (Qulipta) (CP.PHAR.566)

Ambetter

4Q 2026 annual review: no significant changes; references reviewed and updated.

Tofersen (Qalsody) (CP.PHAR.591)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Donanemab-azbt (Kisunla) (CP.PHAR.594)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; references reviewed and updated.

Leniolisib (Joenja) (CP.PHAR.597)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; references reviewed and updated.

Lifileucel (Amtagvi) (CP.PHAR.598)

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

4Q 2026 annual review: added ICHRA line of business; references reviewed and updated.

Zavegepant (Zavzpret) (CP.PHAR.630)

Ambetter

4Q 2026 annual review: no significant changes; added bypass for IL HIM per IL HB 5395 for requests of monthly quantities > 1 box of 6 nasal spray devices per month; references reviewed and updated.

Avacincaptad pegol (Izervay) (CP.PHAR.641)

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

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

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

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

4Q 2026 annual review: no significant changes to criteria; removed requirement for body weight; added ICHRA line of business; references reviewed and updated.

Niraparib and Abiraterone (Akeega) (CP.PHAR.645)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; references reviewed and updated.

DaxibotulinumtoxinA-lanm (Daxxify) (CP.PHAR.651)

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

4Q 2026 annual review: no significant changes; references reviewed and updated.

Elranatamab-bcmm (Elrexfio) (CP.PHAR.652)

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

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Melphalan for Hepatic Delivery (Hepzato) (CP.PHAR.653)

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

4Q 2026 annual review: added ICHRA line of business; references reviewed and updated.

Motixafortide (Aphexda) (CP.PHAR.655)

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

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

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

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Crinecerfont (Crenessity) (CP.PHAR.692)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Denileukin Diftitox-cxdl (Lymphir) (CP.PHAR.693)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; for Commercial approval duration, added injectable standard language of “6 months or to the member’s renewal date, whichever is longer”; added ICHRA line of business; references reviewed and updated.

Revakinagene taroretcel-lwey (Encelto) (CP.PHAR.697)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Vanzacaftor-tezacaftor-deutivacaftor (Alyftrek) (CP.PHAR.700)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; references reviewed and updated.

Inavolisib (Itovebi) (CP.PHAR.702)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; references reviewed and updated.

Nemolizumab-ilto (Nemluvio) (CP.PHAR.703)

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

4Q 2026 annual review: no significant changes; references reviewed and updated.

Zolbetuximab-clzb (Vyloy) (CP.PHAR.705)

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

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Zopapogene Imadenovec (Papzimeos) (CP.PHAR.730)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; references reviewed and updated.

Delgocitinib (Anzupgo) (CP.PHAR.744)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added Ebglyss and Nelumvio as examples of biologic medications with which concurrent use is excluded; extended initial approval duration from 6 to 12 months for this maintenance medication for a chronic condition; added ICHRA line of business; references reviewed and updated.

Zongertinib (Hernexeos) (CP.PHAR.750)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Rilzabrutinib (Wayrilz) (CP.PHAR.751)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Paltusotide (Palsonify) (CP.PHAR.755)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Suvorexant (Belsomra) (CP.PMN.109)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; references reviewed and updated.

Naldemedine (Symproic) (CP.PMN.112)

Ambetter

4Q 2026 annual review: no significant changes; references reviewed and updated.

L-glutamine (Endari) (CP.PMN.116)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Lubiprostone (Amitiza) (CP.PMN.142)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Isotretinoin (Claravis Absorica Absorica LD Myorisan Zenatane Amnesteem) (CP.PMN.143)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; references reviewed and updated.

Fluorouracil Cream (Tolak) (CP.PMN.165)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Neomycin-fluocinolone cream (Neo-Synalar) (CP.PMN.167)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Ospemifene (Osphena) (CP.PMN.168)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Methylnaltrexone Bromide (Relistor) (CP.PMN.169)

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

4Q 2026 annual review: no significant changes; references reviewed and updated.

Eluxadoline (Viberzi) (CP.PMN.170)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Megestrol Acetate Oral Suspension (CP.PMN.179)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Halobetasol Propionate Lotion (Bryhali, Lexette, Ultravate) (CP.PMN.180)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Calcipotriene-Betamethasone Dipropionate Foam (Enstilar) (CP.PMN.181)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Betamethasone dipropionate (Sernivo) (CP.PMN.182)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Stiripentol (Diacomit) (CP.PMN.184)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; consolidated the 12-month Initial and Continued Approval durations for multiple lines of business into one statement; references reviewed and updated.

Baloxavir Marboxil (Xofluza) (CP.PMN.185)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business references reviewed and updated.

Acyclovir buccal tab (Sitavig) (CP.PMN.210)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Ferric maltol (Accrufer) (CP.PMN.213)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; ICHRA line of business added; references reviewed and updated.

Diazepam (Libervant, Valtoco) (CP.PMN.216)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; in Appendix E removed the Medicaid wording on the NV-specific bypass such that the bypass now applies to all NV lines of business; added ICHRA line of business; references reviewed and updated.

Tazarotene (Arazlo, Fabior, Tazorac) (CP.PMN.244)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; references reviewed and updated.

Ciprofloxacin-Fluocinolone (Otovel) (CP.PMN.249)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Colesevelam (Welchol) (CP.PMN.250)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Metoclopramide (Gimoti) (CP.PMN.252)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

No Coverage Criteria, Recent Label Changes Pending Clinical Policy Update (CP.PMN.255)

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

4Q 2026 annual review: no significant changes; updated Appendix E with revised language for Tennessee; added Texas to Appendix F; references reviewed and updated.

Nifurtimox (Lampit) (CP.PMN.256)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Finerenone (Kerendia) (CP.PMN.266)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added HIM IL bypass for CKD indication; added ICHRA line of business; references reviewed and updated.

Levodopa Inhalation Powder (Inbrija) (CP.PMN.267)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Tenofovir Alafenamide Fumarate (Vemlidy) (CP.PMN.268)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Pilocarpine (Vuity, Qlosi) (CP.PMN.270)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; references reviewed and updated.

Ketorolac nasal spray (Sprix) (CP.PMN.282)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Tapinarof (Vtama) (CP.PMN.283)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Dextromethorphan-bupropion (Auvelity) (CP.PMN.284)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; references reviewed and updated.

Lotilaner (Xdemvy) (CP.PMN.291)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; references reviewed and updated.

Brivaracetam (Briviact) (CP.PMN.297)

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

4Q 2026 annual review: no significant changes; in Appendix D removed the Medicaid wording on the NV-specific bypass such that the bypass now applies to all NV lines of business; added ICHRA line of business; references reviewed and updated.

Aceclidine (Vizz) (CP.PMN.302)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; references reviewed and updated.

Rifaximin (Xifaxan) (CP.PMN.47)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Off-Label Use (CP.PMN.53)

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

4Q 2026 annual review: no significant changes; updated Appendix E with revised language for Tennessee; added Texas to Appendix G; references reviewed and updated.

Clobazam (Onfi, Sympazan) (CP.PMN.54)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; separated the generic redirection for Onfi from the generic redirection for Sympazan since the Onfi redirection is to a generic equivalent (and thus not subject to the state-specific ST bypass); in Appendix D removed the Medicaid wording on the NV-specific bypass such that the bypass now applies to all NV lines of business; added ICHRA line of business; consolidated the 12-month Initial and Continued Approval durations for multiple lines of business into one statement; references reviewed and updated.

Quantity Limit Override and Dose Optimization (CP.PMN.59)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Ophthalmic corticosteroids (Lotemax, Durezol, Alrex, Pred Mild, FML Forte, Maxidex) (HIM.PA.03)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; references reviewed and updated.

Insulin glargine (Basaglar, Lantus, Rezvoglar, Toujeo) (HIM.PA.09)

Ambetter

4Q 2026 annual review: no significant changes; removed all  references to unbranded Lantus as it is no longer available; references reviewed and updated.

Brand Name Override and Non-Formulary Medications (HIM.PA.103)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added Nevada to Appendix E; updated Appendix F with revised language for Tennessee; added ICHRA line of business; references reviewed and updated.

Naproxen oral suspension (Naprosyn) (HIM.PA.130)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Doxepin (Silenor, Prudoxin, Zonalon) (HIM.PA.147)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; references reviewed and updated.

Prucalopride (Motegrity) (HIM.PA.159)

Ambetter

4Q 2026 annual review: no significant changes; references reviewed and updated.

Naloxegol (Movantik) (HIM.PA.167)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Methoxsalen (Uvadex) (HIM.PA.17)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; references reviewed and updated.

Insulin detemir (Levemir) (HIM.PA.171)

Ambetter

4Q 2026 annual review: no significant changes; references reviewed and updated.

Age Limit Override (HIM.PA.177)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added Appendices D, E, and F in support of existing criteria; added ICHRA line of business; references reviewed and updated.

Halcinonide (Halog) (HIM.PA.20)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Topical Acne Treatment (HIM.PA.71)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; references reviewed and updated.

Testosterone (Androderm) (HIM.PA.87)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; references reviewed and updated.

Uridine triacetate (Vistogard) (HIM.PA.SP55)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes; added ICHRA line of business; references reviewed and updated.

Eptinezumab (Vyepti) (HIM.PA.SP64)

Ambetter

4Q 2026 annual review: no significant changes; references reviewed and updated.

Erenumab-aooe (Aimovig) (HIM.PA.SP65)

Ambetter

4Q 2026 annual review: no significant changes; references reviewed and updated.

Fremanezumab-vfrm (Ajovy) (HIM.PA.SP66)

Ambetter

4Q 2026 annual review: no significant changes; references reviewed and updated.

Galcanezumab-gnlm (Emgality) (HIM.PA.SP67)

Ambetter

4Q 2026 annual review: no significant changes; references reviewed and updated.

Udenafil_PEPP (CP.PHAR.557_PEPP)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; no significant changes as the drug is not yet FDA-approved; references reviewed and updated.

Dasiglucagon (ZP4207)_PEPP (CP.PHAR.642_PEPP)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes as drug is still not FDA approved; added ICHRA line of business; references reviewed and updated.

Glepaglutide (ZP1848)_PEPP (CP.PHAR.694_PEPP)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes as drug is still not FDA approved; added ICHRA line of business; references reviewed and updated.

Tabelecleucel (Tab-cel)_PEPP (CP.PHAR.747_PEPP)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; updated language under Policy/Criteria to effectively redirect prior authorization reviews to Precision Drug Action Committee(PDAC) Utilization Management Review; no significant changes as the drug is not yet FDA-approved; references reviewed and updated.

Sonpiretigene Isteparvovec (MCO 010)_PEPP (CP.PHAR.749_PEPP)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes as drug is still not FDA approved; added ICHRA line of business; references reviewed and updated.

Idebenone_PEPP (CP.PHAR.752_PEPP)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes as the drug is not yet FDA-approved; added ICHRA line of business; references reviewed and updated.

Bitopertin_PEPP (CP.PHAR.758_PEPP)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; no significant changes as drug is not yet FDA-approved; references reviewed and updated.

Sirolimus-Pegadricase (NASP)_PEPP (CP.PHAR.760_PEPP)

Ambetter/Ambetter Health

4Q 2026 annual review: no significant changes as the drug is not yet FDA-approved; added ICHRA line of business; references reviewed and updated.

GLP-1 receptor agonists_PEPP (HIM.PA.53_PEPP)

Ambetter/Ambetter Health

4Q 2026 annual review: converted Rybelsus pre-emptive criteria to reflect FDA approval for reduction of major adverse cardiovascular events in diabetic patients at high risk; no changes to Ozempic pre-emptive criteria as it has not yet been FDA-approved for PAD; updated policy to align with currently active GLP-1 criteria; added ICHRA line of business; references reviewed and updated.

Delpacibart Zotadirsen (AOC 1044) (CP.PHAR.799)

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

Policy created pre-emptively

Deucrictibant (PHVS416) (CP.PHAR.800)

Ambetter/Ambetter Health

Policy created pre-emptively

Encaleret (CLTX-305) (CP.PHAR.801)

Ambetter/Ambetter Health

Policy created pre-emptively

Medoretgene parvec (AAV-AIPL1) (CP.PHAR.802)

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

Policy created pre-emptively

Povetacicept (ALPN-303) (CP.PHAR.803)

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

Policy created pre-emptively

Zeleciment rostudirsen (DYNE-251) (CP.PHAR.804)

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

Policy created pre-emptively

Leuprolide Acetate (Lupron Eligard Lupaneta Pack Fensolvi Camcevi Vabrinity) (CP.PCH.53)

Ambetter

4Q 2026 annual review: added requirement for age ≥ 18 years for salivary gland tumors and uterine sarcoma; per NCCN compendium for breast cancer added requirement that member is premenopausal or male and prescribed in combination with endocrine therapy; for infertility/fertility preservation coverage added the following clarification: ‘HIM line of business: pharmacy benefit coverage restrictions by state. Please refer to plan specific evidence of coverage (EOC) document for benefit coverage.’; added S9560 HCPCS code; references reviewed and updated.

Lebrikizumab (Ebglyss) (CP.PCH.58)

Ambetter

4Q 2026 annual review: for initial and continued therapy, added option for every 8-week maintenance dosing per PI; added Nemluvio as an example of biologic medication for which concurrent use is excluded; references reviewed and updated.

Venetoclax (Venclexta) (CP.PHAR.129)

Ambetter/Ambetter Health

4Q 2026 annual review: for CLL/SLL, added Brukinsa as first-line therapy option, removed requirement for absence of del(17p)/TP53 mutation, added both Brukinsa and Calquence as subsequent therapy combination options, and added additional treatment options for histologic (Richter) transformation  per NCCN; for mantle cell lymphoma that is positive for TP53 mutation, replaced combination therapy Gazyva + Imbruvica with combination therapy Gazyva + Brukinsa per NCCN; for AML, expanded therapy options for inclusion of Inqovi and for relapsed/refractory disease, therapy-related AML, and poor-risk AML per NCCN; for BPDCN, removed option for palliative intent of systemic disease and added option for Venclexta prescribed as  treatment induction per NCCN; for systemic light chain amyloidosis, added requirement for t(11;14) translocation per NCCN; for MDS, expanded combination therapy options to include Inqovi per NCCN; for Philadelphia chromosome negative B-cell ALL, added option for relapsed/refractory disease per NCCN; for ALL, added indication option for Philadelphia chromosome-positive B-cell ALL per NCCN; for continued therapy for AML, replaced named combination therapy agents with “combination therapy;” added ICHRA line of business; references reviewed and updated.

Infertility and Fertility Preservation (CP.PHAR.131)

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

4Q 2026 annual review: added ICHRA line of business; removed each states specific evidence of coverage language (EOC) and instead added language to refer to plan specific EOC document for benefit coverage; for female infertility and fertility preservation, added criterion that member is premenopausal; added off-label criteria for steroid-refractory acute graft-versus-host disease as supported by NCCN; references reviewed and updated,

Ivosidenib (Tibsovo) (CP.PHAR.137)

Ambetter/Ambetter Health

4Q 2026 annual review: for MDS, revised “disease progression, no response, or intolerance to prior systemic treatment” to “Prescribed as subsequent therapy,” added requirement for lower-risk MDS to apply to this revision, and added requirement for either clinically relevant thrombocytopenia/neutropenia or symptomatic anemia per NCCN; for cholangiocarcinoma, added option for unresectable disease per NCCN; for chondrosarcoma, added option for metastatic chondrosarcoma and monotherapy use requirement per NCCN; for gliomas, added option for other high-grade glioma per NCCN; added ICHRA line of business; references reviewed and updated.

Lenvatinib (Lenvima) (CP.PHAR.138)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; for DTC, added option for use in locoregionally invasive disease and after thyroidectomy; for RCC, added option for use as a single agent as subsequent therapy if RCC histology is clear cell per NCCN; references reviewed and updated.

Mogamulizumab-kpkc (Poteligeo) (CP.PHAR.139)

Ambetter/Ambetter Health

4Q 2026 annual review: for ATLL initial therapy, removed “prescribed as a single agent” and added option for use in combination with CHOP per NCCN; added ICHRA line of business; references reviewed and updated.

Miglustat (Zavesca) (CP.PHAR.164)

Ambetter/Ambetter Health

Updated NPC diagnostic criterion to require confirmation by biallelic pathogenic variants in NPC1 or NPC2 gene per updated international consensus guidelines.

Goserelin Acetate (Zoladex) (CP.PHAR.171)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; for ovarian cancer, salivary gland tumors, and uterine sarcoma added requirement for age ≥ 18 years; per NCCN compendium for ovarian cancer added requirement prescribed as a single agent; per NCCN compendium for salivary gland tumors added requirement prescribed as a single agent or in combination with abiraterone and prednisone; references reviewed and updated.

Triptorelin pamoate (Trelstar, Triptodur) (CP.PHAR.175)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; for breast cancer, salivary gland tumors, and uterine sarcoma added requirement for age ≥ 18 years; per NCCN compendium for breast cancer added requirement that member is premenopausal or male and prescribed in combination with endocrine therapy; references reviewed and updated.

Obinutuzumab (Gazyva) (CP.PHAR.305)

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

4Q 2026 annual review: separated FL criteria from “B-Cell Lymphomas and Tumors with B-Cell Predominance” and renamed existing criteria “Additional NCCN Recommended Uses (off-label);” for CLL/SLL, added treatment option combinations for first-line therapy and histologic (Richter) transformation per NCCN; for FL, added NCCN-supported regimens for second-line and subsequent therapy; added indication of Waldenstrom macroglobulinemia/lymphoplasmacytic lymphoma per NCCN; for mantle cell lymphoma, added option for use as a substitute for rituximab at provider’s discretion per NCCN; added ICHRA line of business; references reviewed and updated.

Bendamustine (Belrapzo, Bendeka, Treanda, Vivimusta) (CP.PHAR.307)

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

4Q 2026 annual review: added ICHRA line of business; for DLBCL and high-grade B-cell lymphomas, removed specification for intention to proceed to transplant; for pediatric HL, removed “as re-induction or subsequent therapy” per NCCN; references reviewed and updated.

Carfilzomib (Kyprolis) (CP.PHAR.309)

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

4Q 2026 annual review: added ICHRA line of business; for WM/LPL, added option to be prescribed for previously treated disease per NCCN; references reviewed and updated.

Romidepsin (Istodax) (CP.PHAR.314)

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

4Q 2026 annual review: for initial therapy, added bypass of failure of one prior systemic therapy for subcutaneous panniculitis-like T-cell lymphoma per NCCN; added ICHRA line of business; references reviewed and updated.

Cetuximab (Erbitux) (CP.PHAR.317)

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

4Q 2026 annual review: per NCCN – for CRC, clarified that use as a single agent or in combination with FOLFIRI, FOLFOX, CapeOX or irinotecan is only for KRAS/NRAS/BRAF wild-type disease, added options for use in combination with Braftovi with or without FOLFIRI or CapeOx for BRAF V600E mutation positive disease, allowed use as initial therapy in combination with Lumakras or Krazati for KRAS G12C mutation positive disease, limited to left-sided cancer only for initial therapy requests for KRAS/NRAS/BRAF wild-type colon cancer, and clarified that disease is either dMMR/MSI-H/POLE/POLD1 or pMMR/MSS; added off-label criteria for appendiceal cancers and small bowel adenocarcinoma; added ICHRA line of business; references reviewed and updated.

Eribulin mesylate (Halaven) (CP.PHAR.318)

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

4Q 2026 annual review: for STS, added borderline/malignant phyllodes tumor of breast subtype and added subsequent therapy bypass for liposarcoma and epithelioid hemangioendothelioma subtype per NCCN; added ICHRA line of business; references reviewed and updated.

Panitumumab (Vectibix) (CP.PHAR.321)

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

4Q 2026 annual review: added ICHRA line of business; added off-label small bowel adenocarcinoma and appendiceal neoplasms and cancers per NCCN; for CRC per NCCN, removed specification for BRAF V600E mutation positive disease for use in combination with Braftovi, removed specification for KRAS G12C positive disease for use in combination with Lumakras or Krazati; references reviewed and updated.

Temsirolimus (Torisel) (CP.PHAR.324)

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

4Q 2026 annual review: for soft tissue sarcoma, added option for pediatric rhabdomyosarcoma indication per NCCN; added age bypass for pediatric rhabdomyosarcoma; added ICHRA line of business; references reviewed and updated.

Ribociclib (Kisqali, Kisqali Femara) (CP.PHAR.334)

Ambetter/Ambetter Health

4Q 2026 annual review: for breast cancer, added option to be prescribed in combination with Etcamah if disease is ESR1 mutated per Etcamah’s FDA labeled indication; added ICHRA line of business; references reviewed and updated.

Abemaciclib (Verzenio) (CP.PHAR.355)

Ambetter/Ambetter Health

4Q 2026 annual review: for breast cancer, added use in combination with Inluriyo after disease progression on endocrine therapy for advanced, recurrent, or metastatic disease supported by NCCN; added if disease is ESR1 mutated, prescribed in combination with Etcamah per Etcamah’s FDA labeled indication; for endometrial carcinoma, added option to be prescribed in combination with fulvestrant per NCCN; added off-label criteria for meningiomas per NCCN; added ICHRA line of business; references reviewed and updated.

Enasidenib (Idhifa) (CP.PHAR.363)

Ambetter/Ambetter Health

4Q 2026 annual review: for AML, added induction, post-induction, or consolidation therapy use; added monotherapy use requirement for relapsed/refractory AML per NCCN; added MDS indication criteria per NCCN; for continued therapy, revised “AML” to “a covered indication;” revised continued therapy authorization duration for Commercial line of business from “12 months or duration of request, whichever is less” to “12 months;” added ICHRA line of business; references reviewed and updated.

Neratinib (Nerlynx) (CP.PHAR.365)

Ambetter/Ambetter Health

4Q 2026 annual review: for breast cancer, added off-label criteria for HER2-negative disease per NCCN; added ICHRA line of business; references reviewed and updated.

Corticosteroids for Ophthalmic Injection (Dextenza, Iluvien, Ozurdex, Retisert, Xipere, Yutiq) (CP.PHAR.385)

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

Added step through of intravitreal steroid injections back to all indications as Triesence is now available for macular edema and DME.

Azacitidine (Vidaza, Onureg) (CP.PHAR.387)

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

4Q 2026 annual review: for myelodysplastic syndromes and myeloproliferative neoplasms, clarified that requests for generic azacitidine should be for the SC/IV formulation; for peripheral T-cell lymphomas, added progressive as an additional disease qualifier option per NCCN; added off-label criteria for Onureg for T-cell acute lymphoblastic leukemia per NCCN; added ICHRA line of business; updated Appendix E with revised language for Tennessee; references reviewed and updated.

Cemiplimab-rwlc (Libtayo) (CP.PHAR.397)

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

4Q 2026 annual review: for off-label uses, added additional use as neoadjuvant therapy for small bowel adenocarcinoma, clarified that use in rectal and colon cancer should be in those with no previous treatment with checkpoint inhibitor/immunotherapy, added use in appendiceal cancer, and added additional use for combination or single agent therapy for anal carcinoma per NCCN; added ICHRA line of business; references reviewed and updated.

Duvelisib (Copiktra) (CP.PHAR.400)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; added off-label indication for mycosis fungoides/Sezary syndrome per NCCN; references reviewed and updated.

Larotrectinib (Vitrakvi) (CP.PHAR.414)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; clarified policy applies to generic Larotrectinib; removed requirement that request does not exceed health-plan approved quantity limit; updated Appendix E with revised language for Tennessee; references reviewed and updated.

Valrubicin (Valstar) (CP.PHAR.439)

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

4Q 2026 annual review: added ICHRA line of business; removed specification of CIS disease; added option for use as subsequent treatment for muscle invasive disease in combination with TURBT per NCCN; added option for use in CIS, Ta, or T1 local recurrence or persistent disease in a preserved bladder for disease treated with curative intent per NCCN; references reviewed and updated.

Entrectinib (Rozlytrek) (CP.PHAR.441)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; for NTRK Fusion-Positive Cancer, clarified NTRK 1/2/3-gene fusion; clarified solid tumors examples in Appendix D per NCCN compendium; references reviewed and updated.

Fedratinib (Inrebic) (CP.PHAR.442)

Ambetter

4Q 2026 annual review: for myeloid/lymphoid neoplasms with eosinophilia removed redirection to Jakafi per NCCN and specialist feedback; references reviewed and updated.

Nadofaragene firadenovec-vncg (Adstiladrin) (CP.PHAR.461)

Ambetter/Ambetter Health

4Q 2026 annual review: increased initial and continued therapy approval duration to 12 months for this maintenance medication for a chronic condition; references reviewed and updated.

Antithymocyte Globulin (Atgam, Thymoglobulin) (CP.PHAR.506)

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

4Q 2026 annual review: added ICHRA line of business; for Atgam, added option to be prescribed for GVHD prophylaxis per NCCN; references reviewed and updated.

Lomustine (Gleostine) (CP.PHAR.507)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; clarified policy/criteria applies to generic lomustine; for all indications, clarified member must use generic lomustine for brand Gleostine requests; references reviewed and updated.

Arimoclomol (Miplyffa) (CP.PHAR.510)

Ambetter/Ambetter Health

4Q 2026 annual review: updated NPC diagnostic criterion to require confirmation by biallelic pathogenic variants in NPC1 or NPC2 gene per updated international consensus guidelines; added ICHRA line of business; references reviewed and updated.

Plasminogen (Ryplazim) (CP.PHAR.513)

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

4Q 2026 annual review: revised diagnostic criteria to clarify “PLG mutation” as “biallelic mutations in the PLG gene,” to require signs/symptoms of C-PGLD, and to meet either the plasminogen activity level ≤ 45% or the biallelic mutations in PLG gene as a diagnostic criterion; added ICHRA line of business; references reviewed and updated.

Ophthalmic Riboflavin (Photrexa, Photrexa Viscous, Epioxa HD, Epioxa) (CP.PHAR.536)

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

Added Epioxa HD and Epioxa to criteria per local market request.

Belumosudil (Rezurock) (CP.PHAR.552)

Ambetter/Ambetter Health

4Q 2026 annual review: clarified systemic immunosuppressant as non-steroidal; added step therapy bypass for IL HIM per IL HB 5395; added ICHRA line of business; references reviewed and updated.

Chlorambucil (Leukeran) (CP.PHAR.554)

Ambetter/Ambetter Health

4Q 2026 annual review: removed off-label use in marginal zone lymphomas as this is no longer NCCN supported; revised “classic” follicular lymphoma to “giant” follicular lymphoma to align with FDA labeling as this use is no longer NCCN supported; added use in malignant lymphomas including lymphosarcoma in line with FDA labeling; added ICHRA line of business; references reviewed and updated.

Mitapivat (Pyrukynd, Aqvesme) (CP.PHAR.558)

Ambetter/Ambetter Health

4Q 2026 annual review: for PK deficiency, revised initial approval duration to 12 months; added ICHRA line of business; references reviewed and updated.

Tisotumab vedotin-tftv (Tivdak) (CP.PHAR.561)

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

4Q 2026 annual review: removed monotherapy requirement from continued therapy; added ICHRA line of business; references reviewed and updated.

Cipaglucosidase alfa-atga--miglustat (Pombiliti-Opfolda) (CP.PHAR.567)

Ambetter/Ambetter Health

Updated NPC diagnostic criterion to require confirmation by biallelic pathogenic variants in NPC1 or NPC2 gene per updated international consensus guidelines; added ICHRA line of business.

Lecanemab-irmb (Leqembi, Leqembi Iqlik) (CP.PHAR.596)

Ambetter/Ambetter Health

4Q 2026 annual review: added the new indication for Leqembi Iqlik for treatment initiation; references reviewed and updated.

Quizartinib (Vanflyta) (CP.PHAR.646)

Ambetter/Ambetter Health

4Q 2026 annual review: added single agent therapy requirement for relapsed/refractory AML per NCCN; for continued therapy, revised “AML” to “a covered indication;” added ICHRA line of business; references reviewed and updated.

Resmetirom (Rezdiffra) (CP.PHAR.647)

Ambetter/Ambetter Health

4Q 2026 annual review: revised exclusion for concurrent prescribing with Wegovy to concurrent initiation with Wegovy for initial criteria per updated guidelines; revised failure of ≥ 6-month trial of Wegovy to “Inadequate response to ≥ 12-month of Wegovy” per updated guidelines; removed concurrent prescribing exclusion from continued therapy criteria; added that member has not progressed to cirrhosis for continued therapy; added ICHRA line of business; references reviewed and updated.

Rozanolixizumab-noli (Rystiggo) (CP.PHAR.648)

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

4Q 2026 annual review: for gMG, added Imaavy and Uplizna to the list of therapies that Rystiggo should not be prescribed concurrently with; added ICHRA line of business; references reviewed and updated.

Talquetamab-tgvs (Talvey) (CP.PHAR.649)

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

4Q 2026 annual review: added ICHRA line of business; added option to be prescribed as bridge to BCMA CAR-T therapy per NCCN; references reviewed and updated.

Momelotinib (Ojjaara) (CP.PHAR.654)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; added off-label criteria for myeloid or lymphoid neoplasm with eosinophilia and Janus kinase 2 arrangement per NCCN category 2A recommendation; references reviewed and updated.

Repotrectinib (Augtyro) (CP.PHAR.667)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; for NTRK fusion-positive cancer, added option for use in unresectable disease and simplified criteria by removal of requirement that disease has progressed following treatment with no satisfactory alternative therapy; clarified solid tumors examples Appendix D per NCCN compendium; references reviewed and updated.

Levacetylleucine (Aqneursa) (CP.PHAR.682)

Ambetter/Ambetter Health

4Q 2026 annual review: updated NPC diagnostic criterion to require confirmation by biallelic pathogenic variants in NPC1 or NPC2 gene per updated international consensus guidelines; references reviewed and updated.

Nogapendekin alfa inbakicept-pmln (Anktiva) (CP.PHAR.684)

Ambetter/Ambetter Health

4Q 2026 annual review: extended initial approval duration from 6 months to 12 months for this chronic condition; references reviewed and updated.

Axatilimab-csfr (Niktimvo) (CP.PHAR.691)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; added 9 mg/0.9 mL and 22 mg/2.2 mL dosage strengths; references reviewed and updated.

Lazertinib (Lazcluze) (CP.PHAR.695)

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

4Q 2026 annual review: added options for Lazcluze monotherapy and for combination Lazcluze+Rybrevant as subsequent therapy following Tagrisso-based therapy per NCCN; added ICHRA line of business; references reviewed and updated.

Palopegteriparatide (Yorvipath) (CP.PHAR.696)

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

4Q 2026 annual review: added requirement that member does not have acute post-surgical hypoparathyroidism; added ICHRA line of business; references reviewed and updated.

Seladelpar (Livdelzi) (CP.PHAR.698)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; added requirement that Livdelzi is not prescribed concurrently with Iqirvo to initial and continued therapy to prevent duplicate therapy; added requirement that member does not have decompensated cirrhosis (e.g., ascites, variceal bleeding, hepatic encephalopathy) per prescribing information; references reviewed and updated.

Vorasidenib (Voranigo) (CP.PHAR.699)

Ambetter/Ambetter Health

4Q 2026 annual review: added monotherapy requirement to continued therapy; added ICHRA line of business; references reviewed and updated.

Diazoxide Choline (Vykat XR) (CP.PHAR.701)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; for diagnosis of PWS added that genetic testing indicates mutation on chromosome 15; references reviewed and updated.

Dordaviprone (Modeyso) (CP.PHAR.745)

Ambetter/Ambetter Health

4Q 2026 annual review: added option for use in high-grade glioma and added recurrent as an additional disease qualifier per NCCN; added ICHRA line of business; references reviewed and updated.

Gemcitabine Intravesical System (Inlexzo) (CP.PHAR.753)

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

4Q 2026 annual review: added ICHRA line of business; added option for use in NMBIC with Ta or T1 papillary tumors per NCCN; references reviewed and updated.

Imlunestrant (Inluriyo) (CP.PHAR.754)

Ambetter/Ambetter Health

4Q 2026 annual review: added recurrent unresectable as additional qualifier option and added option for use in combination with Verzenio per NCCN; added ICHRA line of business; references reviewed and updated.

Remibrutinib (Rhapsido) (CP.PHAR.756)

Ambetter/Ambetter Health

4Q 2026 annual review: for antihistamine trials, revised required dose from maximum “indicated” to “tolerated” to allow for up to 4-fold standard dosing per practice guidelines; added ICHRA line of business; references reviewed and updated.

Lapatinib (Tykerb) (CP.PHAR.79)

Ambetter/Ambetter Health

4Q 2026 annual review: removed off-label criteria for colorectal cancer as Tykerb was removed as a treatment option in NCCN guidelines Colon Cancer version 1.2026; added off-label criteria for sellar tumors, intracranial and spinal ependymoma (excluding subependymoma),and NF2-related progressive or symptomatic vestibular schwannoma (central nervous system cancers) per NCCN; added lapatinib to medically necessary statement as generic requires prior authorization; added ICHRA line of business; references reviewed and updated.

Bevacizumab (Alymsys, Avastin, Avzivi, Jobevne, Lytenava, Mvasi, Vegzelma, Zirabev) (CP.PHAR.93)

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

4Q 2026 annual review: added ICHRA line of business; updated Appendix E with revised language for Tennessee; for RCC, added option for use in combination with interferon alfa per FDA label; for the following oncology indications, revised the following per NCCN: added use in appendiceal neoplasms and cancers, clarified glioblastoma includes gliosarcoma, added use in NF2-related schwannomas, removed prescribed by in combination with IROX for CRC, for epithelial ovarian, fallopian tube, and primary peritoneal cancer, added use in combination with paclitaxel for small cell carcinoma (hypercalcemic type) recurrence therapy, added use in combination with FOLFIRI for platinum-resistant disease, added use in combination with paclitaxel and Keytruda for platinum-resistant disease; for ophthalmology uses, revised maximum dose for off-label uses to 1.25 mg per AAO guidelines and Clinical Pharmacology; RT4: added newly approved intravitreal formulation Lytenava for nAMD; separated FDA approved indication sections into oncology indications and ophthalmology indications; for oncology indications, added criterion that request is for Avastin, Alymsys, Avzivi, Jobevne, Mvasi, Vegzelma, or Zirabev; references reviewed and updated.

Continuous Glucose Monitors (CP.PMN.214)

Ambetter

4Q 2026 annual review: added requirement that age is in line with the FDA-approved age for the requested product; for continued therapy requests for a new receiver, modified reasonable/useful lifetime from 5 to 3 years per various CGM user guides; incorporated existing quantity limit for receivers from approval duration into criteria; references reviewed and updated.

Brensocatib (Brinsupri) (CP.PMN.303)

Ambetter/Ambetter Health

4Q 2026 annual review: for diagnosis, added clarification that member does not have cystic fibrosis; added ICHRA line of business; references reviewed and updated.

Azelaic Acid (Finacea foam) (HIM.PA.119)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; removed Finacea topical gel dosage form per discontinuation of brand Finacea gel; removed redirection to oral minocycline per non-formulary status; references reviewed and updated.

Nitazoxanide (Alinia) (HIM.PA.152)

Ambetter/Ambetter Health

4Q 2026 annual review: added ICHRA line of business; added option for extended off-label dosing requests for the treatment of cryptosporidiosis in an immunocompromised patient per IDSA/CDC/NIH guidelines; references reviewed and updated.

Off-label Policy (HIM.PA.154)

Ambetter/Ambetter Health

4Q 2026 annual review: updated Appendix E with revised language for Tennessee; added Nevada to Appendix H; added ICHRA line of business; references reviewed and updated.

Palbociclib (Ibrance) (HIM.PA.173)

Ambetter

4Q 2026 annual review: for breast cancer, added option for  combination use with fulvestrant and Revtorpyk per NCCN; added bypass to Kisqali and Verzenio redirection for combination use with Revtorpyk; added option for combination use with Etcamah if disease is ESR1 mutated per Etcamah’s FDA labeled indication; added off-label criteria for uterine neoplasms per NCCN; references reviewed and updated.

No Coverage Criteria (HIM.PA.33)

Ambetter/Ambetter Health

4Q 2026 annual review: for FDA-approved doses, added requirement that request does not exceed health plan-approved quantity limit per CDPA request; updated Appendix E with revised language for Tennessee; added Nevada to Appendix F; added ICHRA line of business;  references reviewed and updated.