Effective February 1, 2022: Pharmacy and Biopharmacy Policies

Abatacept (Orencia) (CP.PHAR.241)

Ambetter

Policy updates include:

• For RA added Actemra to redirect options and modified to require a trial of all
• For PsA removed Simponi as a redirect option and modified to require a trial of all
• For Xeljanz redirection requirements, added bypass for members with cardiovascular risk, and qualified redirection to apply only for member that has not responded or is intolerant to one or more TNF blockers

Adalimumab (Humira), Adalimumab-atto (Amjevita), Adalimumab-adbm (Cyltezo), Adalimumab-bwwd (Hadlima), Adalimumab-adaz (Hyrimoz) (CP.PHAR.242)

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

Policy updates include:

• For RA added Actemra to redirect options and modified to require a trial of all
• For PsA removed Simponi as a redirect option and modified to require a trial of all
• For AS modified from trial of two to trial of all
• For Xeljanz redirection requirements, added bypass for members with cardiovascular risk, and qualified redirection to apply only for member that has not responded or is intolerant to one or more TNF blockers

Anakinra (Kineret) (CP.PHAR.244)

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

Policy updates include:

• For RA added Actemra to redirect options and modified to require a trial of all
• For Xeljanz redirection requirements, added bypass for members with cardiovascular risk, and qualified redirection to apply only for member that has not responded or is intolerant to one or more TNF blockers

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

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

Policy updates include:

• Added criteria that Onureg be administered as single-agent therapy and option that member could decline consolidation/curative therapy for Onureg request per NCCN compendium

Baricitinib (Olumiant) (CP.PHAR.135)

Ambetter

Policy updates include:

• For RA added Actemra to redirect options and modified to require a trial of all
• Added failure of Xeljanz®/Xeljanz XR® if member has not responded or is intolerant to one or more TNF blockers, unless member has cardiovascular risk and benefits do not outweigh the risk of treatment
• For Xeljanz redirection requirements, added bypass for members with cardiovascular risk, and qualified redirection to apply only for member that has not responded or is intolerant to one or more TNF blockers

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

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

Policy updates include:

• Added Belrapzo
• Added requirements for combination use for CLL, MALT lymphoma, and marginal zone lymphoma per NCCN
• Removed gamma delta requirement from HSTCL
• Added off-label indications of breast-implant ALCL, nodular lymphocyte-predominant HL, pediatric HL, and high-grade B-cell lymphomas
• Removed age requirement for pediatric HL

Bevacizumab (Avastin, Mvasi, Zirabev) (CP.PHAR.93)

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

Policy updates include:

• Added additional NCCN-supported regimens and classifications for colorectal cancer, NSCLC, glioblastoma, cervical cancer, and epithelial ovarian, fallopian tube, or primary peritoneal cancer.
• Added criterion that HCC be classified as Child-Pugh class A disease per NCCN
• Added low-grade WHO grade I glioma to NCCN-supported off-label indication

Biologic DMARDs (HIM.PA.SP60)

Ambetter

Policy updates include:

• Added, If request is for concomitant treatment with Otezla and bDMARD, member has failure, intolerance or contraindication to a 3 consecutive month trial of concomitant treatment with MTX and bDMARD
• For CD, UC, PsO and PsA; revised to allow bypassing Xeljanz if member had cardiovascular risk and benefits do not outweigh the risk of treatment.

Certolizumab (Cimzia) (CP.PHAR.247)

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

Policy updates include:

• For PsA removed Simponi as a redirect option and modified to require a trial of all
• For RA added Actemra to redirect options and modified to require a trial of all
• For Xeljanz redirection requirements, added bypass for members with cardiovascular risk, and qualified redirection to apply only for member that has not responded or is intolerant to one or more TNF blockers

Chlorambucil (Leukeran) (CP.PHAR.554)

Ambetter

Policy updates include:

• Removed coverage for primary cutaneous CD30+ T-cell lymphoproliferative disorder as it is no longer NCCN supported

Cyclosporine (Cequa, Restasis, Verkazia) (CP.PMN.48)

Ambetter

Policy updates include:

• Added Verkazia and corresponding criteria for VKC
• For all indications, added that multiple ophthalmic cyclosporine products should not be used in combination.

Dexlansoprazole (Dexilant) (HIM.PA.05)

Ambetter

Policy updates include:

• Added minimum age requirement per PI

Duvelisib (Copiktra) (CP.PHAR.400)

Ambetter

Policy updates include:

• For CLL/SLL, added requirement for use as a single agent

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

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

Policy updates include:

• Added combination with Margenza and clarified combination with trastuzumab is for 3rd line therapy or beyond for breast cancer per NCCN Compendium
• Removed off-label indication for use in undifferentiated pleomorphic sarcoma per NCCN Compendium

Factor VIII (Human, Recombinant) (CP.PHAR.215)

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

Policy updates include:

• Added a requirement for high utilizers of factor VIII products for routine prophylaxis to use Hemlibra

Factor VIII/von Willebrand Factor Complex (Human – Alphanate, Humate-P, Wilate); von Willebrand Factor (Recombinant – Vonvendi) (CP.PHAR.216)

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

Policy updates include:

• Added a requirement for high utilizers of factor VIII products for routine prophylaxis to use Hemlibra

Flibanserin (Addyi) (CP.PHAR.446)

Ambetter

Policy updates include:

• Added criterion for symptom persistence of 6 months per DSM-5 diagnostic criteria.

Gemtuzumab Ozogamicin (Mylotarg) (CP.PHAR.358)

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

Policy updates include:

• Reduced minimum age requirement for acute promyelocytic leukemia from 18 years to 2 years per NCCN

Golimumab (Simponi, Simponi Aria) (CP.PHAR.253)

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

Policy updates include:

• For AS modified from trial of two to trial of all
• For PsA added redirection to Enbrel, Otezla, Taltz, Xeljanz/Xeljanz XR;
• For RA added Actemra to redirect options and modified to require a trial of all
• For Xeljanz redirection requirements, added bypass for members with cardiovascular risk, and qualified redirection to apply only for member that has not responded or is intolerant to one or more TNF blockers

Guselkumab (Tremfya) (CP.PHAR.364)

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

Policy updates include:

• For PsA removed Simponi as a redirect option and modified to require a trial of all;
• For Xeljanz redirection requirements, added bypass for members with cardiovascular risk, and qualified redirection to apply only for member that has not responded or is intolerant to one or more TNF blockers

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

Ambetter

Policy updates include:

• Added minimum age requirements of at least 18 years for Bryhali and Lexette, and 12 years for Ultravate

Human Growth Hormone (Somapacitan, Somatropin)(HIM.PA.161)

Ambetter

Policy updates include:

• Removed Humatrope as preferred product

Ibrutinib (Imbruvica) (CP.PHAR.126)

Ambetter

Policy updates include:

• Added language for Imbruvica, Rezurock and Jafaki not to be used concurrently  

Idelalisib (Zydelig) (CP.PHAR.133)

Ambetter

Policy updates include:

• For CLL/SLL, added requirement for use as a single agent or in combination with rituximab per NCCN

Inotersen (Tegsedi) (CP.PHAR.405)

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

Policy updates include:

• Added requirement that Tegesedi is not prescribed concurrently with Onpattro

Insulin glargine (Semglee, Toujeo) (HIM.PA.09)

Ambetter

Policy updates include:

• Remove Tresiba from policy as PA is no longer required
• Add Toujeo to policy and revise redirection to require use of Basaglar, Levemir, and Tresiba
• Revise required age to 6 years or older consistent with Semglee and Toujeo prescribing information

Ivermectin (Stromectol, Sklice) (CP.PMN.269)

Ambetter

Policy updates include:

• Added criteria for ivermectin tablets that request is not for the prevention or treatment of coronavirus disease 2019 (COVID-19)

Lapatinib (Tykerb) (CP.PHAR.79)

Ambetter

Policy updates include:

• Added criterion for ovarian ablation or suppression for premenopausal women being treated with Tykerb for breast cancer per NCCN Compendium

Lomustine (Gleostine) (CP.PHAR.507)

Ambetter

Policy updates include:

• For brain tumors, removed temozolomide re-direction per SDC
• For Hodgkin’s lymphoma, added requirement for combination use per FDA label

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

Ambetter

Policy updates include:

• Added requirement for diagnosis confirmation by either genetic or biochemical testing

Obinutuzumab (Gazyva) (CP.PHAR.305)

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

Policy updates include:

• For CLL/SLL, added additional requirements if used as second-line or subsequent therapy per NCCN
• For nodal marginal zone lymphoma, added option for use as first line therapy per NCCN
• For B-cell lymphomas, clarified that I.B.5 does not apply to marginal zone lymphoma

Off-Lable Use (HIM.PA.154)

Ambetter

Policy updates include:

• Added specialist requirement
• Added requirement for trial of two formulary FDA-approved drugs for the indication and/or drugs that are considered the standard of care, when such agents exist
• Added requirement for assessment of contraindications and black box warning
• Added dosing limits requirement

Ozanimod (Zeposia) (CP.PHAR.462)

Ambetter

Policy updates include:

• Modified redirection to require Humira and Simponi

Patisiran (Onpattro) (CP.PHAR.395)

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

Policy updates include:

• Added requirement that Onpattro is not prescribed concurrently with Tegsedi
• Added biopsy requirement

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

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

Policy updates include:

• For ALL, added age restriction of ≤ 21 years for Asparlas and added requirement that the requested agent is prescribed as part of a multi-agent chemotherapeutic regimen per FDA label and NCCN
• For T-cell lymphoma, revised to include only nasal type extranodal NK/T-cell lymphoma, removed extranasal type and aggressive NK cell leukemia, and added hepatosplenic T-cell lymphoma per NCCN

Rituximab (Rituxan), Rituximab-arrx (Riabni), Rituximab-pvvr (Ruxience), Rituximab-abbs (Truxima), RituximabHyaluronidase (Rituxan Hycela) (CP.PHAR.260)

Ambetter

Policy updates include:

• Modified biosimilar redirection requirements for Rituxan to require use of Ruxience, Truxima, and Riabni in a step-wise manner
• Modified requirements for Riabni to require use of Ruxience and Truxima
• Removed age qualification for biosimilar redirection for NHL requests
• For continuation of therapy modified age qualification for biosimilar redirection to apply only to GPA or MPA requests

Romidepsin (Istodax) (CP.PHAR.314)

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

Policy updates include:

• Added a trial of 1 systemic therapy in CTCL coverage as per FDA approved indication

Ruxolitinib (Jakafi) (CP.PHAR.98)

Ambetter

Policy updates include:

• Added language for Imbruvica, Rezurock and Jafaki not to be used concurrently

Secukinumab (Cosentyx) (CP.PHAR.261)

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

Policy updates include:

• For AS, revised redirection requirement from two among the preferred to all of the preferred
• For PsA removed Simponi as a redirect option and modified to require a trial of all
• For Xeljanz redirection requirements, added bypass for members with cardiovascular risk, and qualified redirection to apply only for member that has not responded or is intolerant to one or more TNF blockers

Taliglucerase Alfa (Elelyso) (HIM.PA.162)

Ambetter

Policy updates include:

• Added if diagnosis of GD1, member has experienced failure of Cerezyme or Cerdelga, unless clinically significant adverse effects are experienced or both are contraindicated
• Added if diagnosis of GD3, member has experienced failure of Cerezyme, unless contraindicated or clinically significant adverse effects are experienced

Thioguanine (Tabloid) (CP.PHAR.437)

Ambetter

Policy updates include:

• Moved requirement for use as remission induction/consolidation from ALL to AML per FDA label and NCCN; for ALL
• Specified that disease should be relapsed/refractory
• Added requirement for use in combination with imatinib or Sprycel if Ph+ per NCCN

Tildrakizumab-asmn (Ilumya) (CP.PHAR.386)

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

Policy updates include:

• Added step-wise redirection requiring Taltz, then Enbrel and Otezla

Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase (CP.PHAR.228)

Ambetter

Policy updates include:

• Modified biosimilar redirection requirements for Herceptin to require use of Ogivri, Trazimera, Kanjinti, Ontruzant and Herzuma in a step-wise manner
• For Ontruzant and Herzuma modified redirection to require use of Ogivri, Trazimera, and Kanjinti
• For salivary gland tumor indication added redirection to preferred biosimilars per NCCN Compendium

Ustekinumab (Stelara) (CP.PHAR.264)

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

Policy updates include:

• For PsA removed Simponi as a redirect option and modified to require a trial of all
• For UC added requirement for trial of Humira, Simponi, and Zeposia in a step-wise manner
• Added coverage for dose escalation with Stelara for CD (per A&G report) and UC (per SDC direction) requiring redirection to preferred agents [Humira, Simponi, Zeposia, infliximab (Avsola, Inflectra and Renflexis are preferred)] per SDC
• For Xeljanz redirection requirements, added bypass for members with cardiovascular risk, and qualified redirection to apply only for member that has not responded or is intolerant to one or more TNF blockers

Vedolizumab (Entyvio) (CP.PHAR.265)

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

Policy updates include:

• Modified from trial of Humira or Simponi to trial of all of the following: Humira, Simponi, and Zeposia, in a step-wise manner

Velaglucerase Alfa (VPRIV) (HIM.PA.163)

Ambetter

Policy updates include:

• Added if diagnosis of GD1, member has experienced failure of Cerezyme® or Cerdelga®, unless clinically significant adverse effects are experienced or both are contraindicated;
• Added if diagnosis of GD3, member has experienced failure of Cerezyme, unless contraindicated or clinically significant adverse effects are experienced

Venetoclax (Venclexta) (CP.PHAR.129)

Ambetter

Policy updates include:

• Revised mantle cell lymphoma to require use as a single agent or in combination with rituximab or ibrutinib per NCCN
• Added off-label coverage for BPDCN and multiple myeloma per NCCN

Vincristine Sulfate Liposome Injection (Marqibo) (CP.PHAR.315)

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

Policy updates include:

• Added requirement for use as a single agent per NCCN and pivotal trial