POLICY
| APPLICABLE PRODUCTS
| NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS
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Ruxolitinib (Jakafi, Opzelura) (CP.PHAR.98)
| Ambetter
| Policy updates include:
- For atopic dermatitis and nonsegmental vitiligo, updated concurrent use criteria by adding “Opzelura is not prescribed concurrently with biologic medications (e.g., Dupixent, Adbry)” in initial and continued therapy sections
|
Alirocumab (Praluent) (CP.PHAR.124)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), and CHIP
| Policy updates include:
- For all indications, revised criteria requires to require provider attestation rather than documentation, reduced statin adherence duration from 4 months to 8 weeks, simplified statin trial and failure criteria for moderate- and low-intensity statin regimens to require insufficient therapeutic response to one high intensity statin for 8 weeks or reversible muscle-related symptoms associated with both rosuvastatin and atorvastatin, removed ezetimibe trial criteria
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Sotatercept (Winrevair) (CP.PHAR.657)
| Ambetter, Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), and CHIP
| Policy updates include:
- Drug is now Food and Drug Administration (FDA) approved – criteria updated per FDA labeling:
- Added documentation of platelet count at least 50 x 109/L
- Added quantity limit of one kit per 21 days
- Added Appendix G for recommended vial quantity based on weight-based dose range
- References reviewed and updated
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Topical Acne Treatment (HIM.PA.71)
| Ambetter
| Policy updates include:
- Removed Differin products from criteria (moved Differin criteria to HIM.PA.109 step therapy criteria)
- Added Acanya and Onexton criteria
- Revised BenzaClin criteria to apply to all brand or generic combination products (which includes BenzaClin)
- For combination products, added requirement that the member must use generic combination product if available
- For Evoclin, specified generic clindamycin per available formulary agents
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Biologic and Non-biologic DMARDs (HIM.PA.SP60)
| Ambetter
| Policy updates include:
- For plaque psoriasis, added redirection to Enbrel and Otezla as alternative option with “or” instead of “and” language to list of preferred redirected agents.
- Added branded Cyltezo 40 mg/0.4 mL specific NDCs [0597-0495-40, 0597-0495-50, 0597-0495-60, 0597-0485-20] to list of preferred adalimumab products
- For psoriatic arthritis and polyarticular juvenile idiopathic, added redirection to preferred agent Rinvoq LQ
- For Entyvio, added new dosage form (subcutaneous injection) and removed “request is for intravenous formulation” for Crohn’s disease criteria
- For psoriatic arthritis and plaque psoriasis, added newly approved biosimilar Selarsdi to criteria
- For plaque psoriasis, updated Wezlana age requirement from > 18 years to > 6 years
- For Otezla, added newly approved pediatric extension to 6 years and older for plaque psoriasis criteria
- For Rinvoq, updated criteria to reflect pediatric extension to 2 years and older for psoriatic arthritis
- For Rinvoq, added new FDA approved polyarticular juvenile idiopathic indication and added redirection to preferred agent Rinvoq LQ
- For psoriatic arthritis and polyarticular juvenile idiopathic, added new oral solution dosage form [Rinvoq LQ] to criteria
- For psoriatic arthritis, added redirection to preferred agent Stelara for pediatric Orencia requests
- For Omvoh, added new dosage form [single-dose prefilled syringe 100 mg/mL]
- For Cyltezo, added new 40 mg/0.4 mL dosage strengths for single-dose pen and single-dose prefilled syringe
- For Appendix D, removed supplemental information on Deficiency of Interleukin-1 Receptor Antagonist (DIRA) indication and PHOENIX 2 trial for Stelara.
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