Policy
| Applicable Products
| New Policy Overview or Updated Policy Revisions
|
Ferumoxytol (Feraheme) (CP.PHAR.165)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Modified to redirect from brand Venofer to generic
|
Ferric Carboxymaltose (Injectafer) (CP.PHAR.234)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Modified to redirect from brand Venofer to generic
|
Ferric Derisomaltose (Monoferric) (CP.PHAR.480)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Modified to redirect from brand Venofer to generic
|
Concizumab-mtci (Alhemo) (CP.PHAR.625)
| Ambetter
| Policy updates include:
- Added new indication for hemophilia A and B without inhibitors
- Added continued therapy criterion for provider confirmation that member has discontinued any use of Hemlibra, bypassing agents, FVIII, or FIX products as prophylactic therapy while on Alhemo
|
Vatrombopag (Doptelet, Doptelet Sprinkle) (CP.PHAR.130)
| Ambetter
| Policy updates include:
- Added redirection to eltrombopag (generic Promacta) for immune thrombocytopenia
- Removed redirection to immune globulin if intolerant or contraindicated to systemic corticosteroid
|
Romiplostim (Nplate) (CP.PHAR.179)
| Ambetter, Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), and CHIP
| Policy updates include:
- Added redirection to eltrombopag (generic Promacta) for immune thrombocytopenia and myelodysplastic syndromes
- For immune thrombocytopenia removed redirection to immune globulin if intolerant or contraindicated to systemic corticosteroid
- For immune thrombocytopenia and National Comprehensive Cancer Network (NCCN) supported uses, revised initial approval duration from 6 to 12 months
|
Eltrombopag (Alvaiz, Promacta) (CP.PHAR.180)
| Ambetter
| Policy updates include:
- Added redirection to eltrombopag (generic Promacta)
- For immune thrombocytopenia removed redirection to immune globulin if intolerant or contraindicated to systemic corticosteroid
- For all indications other than hepatitis C-associated thrombocytopenia, revised initial approval duration from 6 to 12 months.*For Health Insurance Marketplace (HIM), if request is through pharmacy benefit, Alvaiz is non-formulary and should not be approved using these criteria
- Refer to the formulary exception policy, HIM.PA.103
|
Fostamatinib (Tavalisse) (CP.PHAR.24)
| Ambetter
| Policy updates include:
- Added redirection to eltrombopag (generic Promacta)
- Removed redirection to immune globulin if intolerant or contraindicated to systemic corticosteroid
- Revised initial approval duration from 6 to 12 months
|
Valbenazine (ingrezza, Ingrezza Sprinkle) (CP.PHAR.340)
| Ambetter
| Policy updates include:
- Added Health Insurance Marketplace (HIM) line of business (removed from CP.PCH.48 which is being retired)
|
Donidalorsen (Dawnzera) (CP.PHAR.717)
| Ambetter, Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), and CHIP
| Policy updates include:
- Added redirection to one of the following: Haegarda, Takhzyro, or Orladeyo
|
Tiopronin Delayed-Release (Thiola EC) (CP.PHAR.725)
| Ambetter
| Policy updates include:
- Added requirement for Thiola EC requests that member must use tiopronin delayed-release (generic Thiola EC)
|
Immune Globulins (CP.PHAR.103)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), and CHIP
| Policy updates include:
- Removed Health Insurance Marketplace (HIM) line of business
- For continued therapy, added language “(or health plan-preferred* immune globulin product)” to continue its usage, unless medical justification supports necessity for immune globulin product switch
|
Perampanel (Fycompa) (CP.PMN.156)
| Ambetter
| Policy updates include:
- Revised policy/criteria to also include generic parampanel and added required use of generic perampanel for brand Fycompa requests
|
Pregabalin (Lyrica, Lyrica CR) (CP.PMN.33)
| Ambetter
| Policy updates include:
- Added clarification for Commercial and Health Insurance Marketplace (HIM), requests for immediate-release pregabalin (Lyrica) should be reviewed using HIM.PA.109 for Health Insurance Marketplace
|
Insulin glargine (Basaglar, Lantus, Rezvoglar, Toujeo) (HIM.PA.09)
| Ambetter
| Policy updates include:
- Removed redirection to branded Semglee and unbranded Tresiba from policy
- Added redirection to insulin glargine-yfgn (unbranded Semglee) and branded Tresiba
|
Step Therapy Criteria (HIM.PA.109)
| Ambetter
| Policy updates include:
- For Aptiom added redirection to eslicarbazepine (generic Aptiom)
- Added pregabalin immediate-release (Lyrica) requiring step through gabapentin and one of the following: antidepressant, anticonvulsant, buspirone, or cyclobenzaprine
- Removed Azelex from policy
|
Inhaled asthma and COPD agents (HIM.PA.153)
| Ambetter
| Policy updates include:
- For long acting beta-2 agonist / long acting muscarinic antagonist and Ohtuvayre requests revised redirection from brand Anoro Ellipta to umeclidinium/vilanterol (Anoro Ellipta authorized generic), added brand Anoro Ellipta to criteria requiring prior authorization as agent is non-formulary and applied redirection to authorized generic
|
Insulin detemir (Levemir) (HIM.PA.171)
| Ambetter
| Policy updates include:
- Removed redirection to branded Semglee and unbranded Tresiba from policy
- Added redirection to insulin glargine-yfgn (unbranded Semglee) and branded Tresiba
|
Mepolizumab (Nucala) (HIM.PA.175)
| Ambetter
| Policy updates include:
- The following revisions we made: for asthma increased required exacerbations from 1 to 2 in the last 12 months, added redirection to Dupixent and Fasenra
- For eosinophilic granulomatosis with polyangiitis added redirection to Fasenra
- For hypereosinophilic syndrome added redirection to corticosteroid and removed criteria requiring member has tried at least one other hypereosinophilic syndrome treatment for a minimum of 4 weeks
- For chronic rhinosinusitis with nasal polyps increased required intranasal corticosteroids from 1 to 2, added redirection to Dupixent for initial and continuation requests
- For chronic obstructive pulmonary disease added redirection to Dupixent
- Revised initial approval durations from 6 to 12 months
|
Tezepelumab (Tezspire) (HIM.PA.176)
| Ambetter
| Policy updates include:
- Removed redirection to Nucala
|
Age Limit Override (HIM.PA.177)
| Ambetter
| Policy includes:
- Requests for indications not approved by the FDA are reviewed with the off-label use policy for the relevant line of business: HIM.PHAR.154 for Ambetter
- All requests for non-formulary drugs should be reviewed against HIM.PA.103 Brand Name Override and Non-Formulary Medications
- Initial Approval Criteria: Age Limit Override (must meet all):
- Request is for a formulary drug; *All requests for non-formulary drugs should be reviewed against HIM.PA.103 Brand Name Override and Non-Formulary Medications
- Request is for a drug other than aspirin; *Aspirin is approvable only for members 45 to 79 years of age
- Member’s age exceeds the health plan-approved age limit;
- One of the following:
- Prescribed indication is FDA-approved;
- Prescribed indication is off-label and use is supported by one of the following:
- The National Comprehensive Cancer Network (NCCN) Drug Information and Biologics Compendium level of evidence 1, 2A, or 2B;
- Evidence from at least two high-quality, published studies in reputable peer-reviewed journals or evidence-based clinical practice guidelines that provide all of the following:
- Adequate representation of the member’s clinical characteristics, age, and diagnosis;
- Adequate representation of the prescribed drug regimen;
- Clinically meaningful outcomes as a result of the drug therapy in question;
- Appropriate experimental design and method to address research questions;
- Micromedex DrugDex® with strength of recommendation Class I or IIa;
- For state(s) with state-specific regulations for supportive evidence for requests in pediatrics where member’s age is beyond the FDA labeled indication and prescribing information;
- Request is not for a benefit-excluded use (e.g., cosmetic);
- Requested dose does not exceed health plan-approved quantity limit; *Requess exceeding the health plan-approved quantity limit should also be reviewed against CP.PMN.59 Quantity Limit Override and Dose Optimization
- Dose does not exceed the FDA-approved maximum recommended dose for the relevant indication;
- Approval duration: 12 months
- Continued Therapy: Age Limit Override (must meet all):
- Member meets one of the following:
- Currently receiving medication via Centene benefit or member has previously met initial approval criteria;
- Member is currently receiving medication and is enrolled in a state and product with continuity of care regulations;
- Member is responding positively to therapy;
- Requested dose does not exceed health plan-approved quantity limit;
- If request is for a dose increase, new dose does not exceed the Food and Drug Administration (FDA)-approved maximum recommended dose for the relevant indication;
- Approval duration: 12 months
|
SGLT2 inhibitors (HIM.PA.91)
| Ambetter
| Policy updates include:
- Removed reference to branded Farxiga where redirection is stated for dapagliflozin
|
Biologic and Non-biologic DMARDs (HIM.PA.SP60)
| Ambetter
| Policy updates include:
- For plaque psoriasis, psoriatic arthritis, Crohn’s disease, and ulcerative colitis initial approval criteria, added redirection to additional preferred ustekinumab products (Pyzchiva, Steqeyma, and Yesintek) and applied to continuation of therapy requests, and for members initiating therapy with Stelara added a single step through preferred agents
- For rheumatoid arthritis, polyarticular juvenile idiopathic arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn’s disease, ulcerative colitis, plaque psoriasis, hidradenitis suppurativa, uveitis initial therapy, added redirection to preferred adalimumab products (adalimumab-aaty, adalimumab-adaz, adalimumab-adbm, Simlandi) and removed redirection to Cyltezo
- For members initiating therapy with Humira initial approval criteria, added single step through preferred agents
|
Immune Globulins (HIM.PA.178)
| Ambetter
| Policy updates include:
- Policy created (adapted from CP.PHAR.103) to remove step through Gammagard, Gammaked and Gamunex for Hyqqvia
|
