Effective May 1, 2025: Pharmacy and Biopharmacy Policies

POLICY

APPLICABLE PRODUCTS

NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS

Ranibizumab (Lucentis, Susvimo), Lucentis Biosimilars (CP.PHAR.186)

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

Policy updates include:

• For Susvimo, updated Food and Drug Administration (FDA) indication to include diabetic macular edema and clarified maximum dose is 2 mg (one 100 mg/mL vial) per 6 months

Panitumumab (Vectibix) (CP.PHAR.321)

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

Policy updates include:

• Added new Food and Drug Administration (FDA)-approved indication of Kirsten rat sarcoma 2 viral oncogene homologue (KRAS) G12C-mutated colorectal cancer
• Removed prior therapy requirement when prescribed for BRAF V600E mutation positive in combination with Braftovi and added clarification that regimen may be “with or without fluorouracil, leucovorin, oxaliplatin (FOLFOX)” per National Comprehensive Cancer Network (NCCN)
• Modified requirement for left-sided colon cancer to also apply to unresectable metachronous metastases per National Comprehensive Cancer Network (NCCN)

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

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

Policy updates include:

• Per updated Food and Drug Administration (FDA) label removal of the one-year duration limit for the treatment of geographic atrophy, removed continued authorization criterion for treatment exceeding 12 months
• Increased Medicaid/Ambetter continued approval duration from 6 months to 12 months for this chronic condition

Eculizumab (Soliris, Bkemv, Epysqli) (CP.PHAR.97)

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

Policy updates include:

• Updated Food and Drug Administration (FDA) approved indication for Soliris to include generalized myasthenia gravis 6 years old pediatric expansion
• For atypical hemolytic uremic syndrome, generalized myasthenia gravis, and neuromyelitis optica spectrum disorder, updated dose maximum and added asterisk stating additional doses of eculizumab may be approved if the member is receiving plasmapheresis, plasma exchange, fresh frozen plasma, or intravenous immunoglobulin
• Added Appendix E to provide supplemental dosing information

Esketamine (Spravato) (CP.PMN.199)

Ambetter

Policy updates include:

• Updated treatment-resistant depression indication to include monotherapy option
• For treatment-resistant depression, revised initial approval maximum to allow for 24 nasal spray devices
• For treatment-resistant depression initial therapy, removed requirement for stabilization and future combination use with an oral antidepressant
• For treatment-resistant depression continued therapy, removed requirement for use in combination with an oral antidepressant

Chenodiol (Chenodal, Ctexli) (CP.PMN.239)

Ambetter

Policy updates include:

• Added criteria for Ctexli, a newly Food and Drug Administration (FDA)-approved brand for the indication of cerebrotendinous xanthomatosis
• For radiolucent gallstones, added criterion requiring request is for Chenodal

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

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

Policy updates include:

• Clarified redirection to two preferred Food and Drug Administration (FDA)-approved drugs applies when requested drug is not first-line therapy

DPP-4 inhibitors (HIM.PA.58)

Ambetter

Policy updates include:

• Added newly approved Brynovin to criteria