POLICY
| APPLICABLE PRODUCTS
| NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS
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Repository Corticotropin Injection (Acthar Gel, Purified Cortrophin Gel) (CP.PHAR.168)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) and CHIP
| Policy update includes:
- For infantile spasm added requirement for documentation of member’s current body surface area (BSA) in m2
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Zilucoplan (Zilbrysq) (CP.PHAR.616)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy update includes:
- Added Bkemv, Epysqli, and Rystiggo to the list of therapies that Zilbrysq should not be prescribed concurrently with
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Non-Calcium Phosphate Binders (CP.PMN.04)
| Ambetter
| Policy update includes:
- For policy/criteria description added references to products available generically
- For Fosrenol added contraindication per updated prescribing information for hypersensitivity to Fosrenol or to any ingredient in the formulation
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Mifepristone (Korlym) (CP.PHAR.101)
| Ambetter
| Policy update includes:
- Added redirection to generic 300 mg tablet for brand Korlym requests
- Revised policy/criteria section to also include generic mifepristone
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Dupilumab (Dupixent) (CP.PHAR.336)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) and CHIP
| Policy update includes:
- For immunotherapy-related pruritus per National Comprehensive Cancer Network (National Comprehensive Cancer Network (NCCN)), removed “refractory” for G3 pruritus, added requirement for no response to 1 month of gabapentinoid therapy for severe pruritus, removed requirement for increased ige level, and added indication for immunotherapy-related bullous dermatitis
- Commercial line of business removed as separate criteria is required
- For chronic rhinosinusitis with nasal polyposis (CRSwNP), added disclaimer statement “Refer to NY.HIM.SP69 for NY CHIP Plans.”
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Adagrasib (Krazati) (CP.PHAR.605)
| Ambetter
| Policy update includes:
- Added generic redirection for initial and continued therapy per template
- Per National Comprehensive Cancer Network (NCCN), for non-small cell lung cancer (NSCLC) removed “locally” from “locally advanced” non-small cell lung cancer (NSCLC) option and for colorectal cancer added monotherapy option
- For non-small cell lung cancer (NSCLC), added redirection to lumakras for members without brain metastases
- For all indications, removed requirement that member has not received prior treatment with lumakras
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Prucalopride (Motegrity) (HIM.PA.159)
| Ambetter
| Policy update includes:
- Added redirection to Trulance
- For continued therapy added similar step requirements to those listed for initial approval requests.
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Tenapanor (Ibsrela, Xphozah) (HIM.PA.174)
| Ambetter
| Policy update includes:
- Removed Xphozah 10 mg strength due to product discontinuation
- For irritable bowel syndrome with constipation revised redirection to Trulance to not be step-wise
- For continued therapy in irritable bowel syndrome with constipation added similar step requirements to those listed for initial approval requests.
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GLP-1 receptor agonists (HIM.PA.53)
| Ambetter
| Policy update includes:
- Removed Bydureon from policy as product has been discontinued
- Added Brenzavvy to Appendix B, for Victoza added generic redirection.
- Added new Rybelsus formulation (R2 tablets: 1.5 mg, 4 mg, and 9 mg)
- Per 2025 American Diabetes Association (ADA) guidelines, added bypass of required non-GLP-1 trial agents for members with metabolic dysfunction-associated steatotic liver disease, metabolic dysfunction-associated steatohepatitis, and heart failure with preserved ejection fraction.
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Dupilumab (Dupixent) (HIM.PA.SP69)
| Ambetter
| Policy update includes:
- For immunotherapy-related pruritus per National Comprehensive Cancer Network (National Comprehensive Cancer Network (NCCN)), removed “refractory” for G3 pruritus, added requirement for no response to 1 month of gabapentinoid therapy for severe pruritus, removed requirement for increased ige level, and added indication for immunotherapy-related bullous dermatitis
- For chronic rhinosinusitis with nasal polyposis (CRSwNP), changed intranasal corticosteroid redirection from double to single step
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Omalizumab (Xolair) (CP.PCH.49)
| Ambetter
| Policy update includes:
- For asthma initial approval criteria, added allowance for Emergency room visit
- For immune checkpoint inhibitor-related severe pruritis, added requirement for no response to 1 month of gabapentinoid therapy per National Comprehensive Cancer Network (National Comprehensive Cancer Network (NCCN))
- Updated Appendix D to include information about atopic dermatitis
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Nivolumab, Nivolumab Hyaluronidase-nvhy (Opdivo, Opdivo Qvantig) (CP.PHAR.121)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy update includes:
- For melanoma, added resected stage IV melanoma
- For classic Hodgkin lymphoma, added option for disease stage III-IV prescribed as primary treatment in combination with AVD (doxorubicin, vinblastine, darcarbazine) per National Comprehensive Cancer Network (NCCN)
- For squamous cell carcinoma of the head and neck, for combination with Erbitux added option for subsequent-line therapy option and added option to be prescribed in combination with Yervoy as first-line therapy per National Comprehensive Cancer Network (NCCN)
- For hepatocellular carcinoma, removed child-pugh classifications, removed specific treatment regimens member has had disease progression following from and revised to prescribed as subsequent line systemic therapy, added member has not been previously treated with immune checkpoint inhibitor therapy, unless following atezolizumab and bevacizumab if prescribed in combination with Yervoy per National Comprehensive Cancer Network (NCCN)
- For esophageal cancer, esophagogastric junction cancer or esophageal adenocarcinoma, added option for planned esophagectomy and to be prescribed as a single agent for microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR) cancers per National Comprehensive Cancer Network (NCCN)
- Added off-label criteria per National Comprehensive Cancer Network (NCCN): for pediatric classic Hodgkin lymphoma – option to be used as re-induction therapy, vaginal cancer for second-line or subsequent therapy as a single agent, chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL) with histologic (Richter) transformation to diffuse B-cell lymphoma – prescribed as a single agent for small cell lung cancer, peritoneal, pericardial and tunica vaginalis testis mesothelioma – as single agent or in combination with Yervoy, single agent usage for Kaposi sarcoma
- Clarified small bowel adenocarcinoma be advanced or metastatic per National Comprehensive Cancer Network (NCCN)
- For off-label recurrent or progressive intermediate trophoblastic tumor, removed requirement for following treatment with platinum-based regimen per National Comprehensive Cancer Network (NCCN)
- Added new subcutaneous formulation Opdivo Qvantiq to policy
- Clarified maximum duration of therapy limit does not exceed 2 years in continued therapy for non-small cell lung cancer applies when in combination with Yervoy and for esophageal squamous cell carcinoma in combination with chemotherapy
- For melanoma and colorectal cancer, added criterion prescribed as a single agent and for Opdivo in combination with Yervoy
- For renal cell carcinoma – for Opdvio, added prescribed as a single agent or in combination with Cabometyx or Yervoy
- For renal cell carcinoma – Opdivo Qvantig, added prescribed as first-line treatment as a single agent following combination treatment with Opdivo and Yervoy, subsequent therapy as a single agent, or in combination with Cabometyx
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Ibrutinib (Imbruvica) (CP.PHAR.126)
| Ambetter
| Policy update includes:
- Per National Comprehensive Cancer Network (NCCN) guidelines added combo use with Venclexta for chronic lymphocytic leukemia (CLL) / small lymphocytic lymphoma (SLL), for histologic transformation of chronic lymphocytic leukemia (CLL) / small lymphocytic lymphoma (SLL) to diffuse large B-cell lymphoma (DLBCL) added requirement for combo use with Opdivo or Keytruda, replaced the terms “Gastric and Nongastric mucosa-associated lymphoid tissue (MALT) lymphoma” with “Extranodal marginal zone lymphoma (MZL) (noncutaneous)” to align with National Comprehensive Cancer Network (NCCN) nomenclature, for Nodal and Extranodal marginal zone lymphoma (MZL) added the requirement for relapsed, refractory, or progressive disease
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Cosyntropin (Cortrosyn) (CP.PHAR.203)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy update includes:
- Added Commercial line of business
- Updated maximum dosing in those age 2 years and older to 0.25 mg as a single-dose per updated prescribing information
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Carglumic Acid (Carbaglu) (CP.PHAR.206)
| Ambetter
| Policy update includes:
- For N-acetyl glutamate synthetase (NAGS) deficiency, added requirement if request is for treatment of acute hyperammonemia, prescribed as adjunctive therapy with other ammonia lowering therapies (e.g., alternative pathway drugs, hemodialysis, and dietary protein restriction)
- To support weight based dosing added requirement for documentation of member’s current weight and/or BSA
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Desmopressin Acetate (DDAVP, Stimate, Nocdurna) (CP.PHAR.214)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy update includes:
- Added the generic versions of Desmopressin Acetate (DDAVP) and Stimate to the “Policy/Criteria” section to clarify that criteria are applicable to the generic versions
- For brand DDAVP injection requests, added redirection to generic desmopressin injection for both initial and continued criteria
- Added Appendix D reference for Stimate brand shortage
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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 update includes:
- Revised desmopressin acetate trial to apply only for age ≥ 2 years
- For Medicaid and Ambetter lines of business, initial therapy approval durations revised to from 3 months to 3 months for surgical/acute bleeding and to 6 months for prophylaxis, and continued therapy approval durations revised from 3 months to 3 months for surgical/acute bleeding and 12 months for prophylaxis
- For Commercial line of business, all prophylaxis approval durations revised to “6 months or to the member’s renewal date, whichever is longer;” .
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Factor VIIa, Recombinant (NovoSeven RT, SevenFact) (CP.PHAR.220)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy update includes:
- Clarified that acquired hemophilia indication is applicable to novoseven RT only
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Atezolizumab (Tecentriq), Atezolizumab-Hyaluronidase (Tecentriq Hybreza) (CP.PHAR.235)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy update includes:
- For Tecentriq Hybreza, updated dosing to include hyaluronidase component and updated contraindications
- For non-squamous non-small cell lung cancer (NSCLC), removed requirement for negative or unknown epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase (ALK) mutation status per National Comprehensive Cancer Network (NCCN)
- For non-small cell lung cancer (NSCLC), added Tecentriq/Tecentriq Hybreza may be continued for maintenance therapy as a single agent (if given as single agent first line therapy or atezolizumab/carboplatin/albumin-bound paclitaxel combination) or in combination with bevacizumab (if atezolizumab/carboplatin/paclitaxel/bevacizumab given) per National Comprehensive Cancer Network (NCCN)
- For small cell lung cancer and cervical cancer, added Tecentriq/Tecentriq Hybreza may be continued as a single agent for maintenance therapy per National Comprehensive Cancer Network (NCCN)
- For hepatocellular carcinoma, added option to be prescribed as adjuvant therapy and removed criteria requiring confirmation of Child-Pugh class A or B status requirement per National Comprehensive Cancer Network (NCCN)
- For melanoma, revised requirement for member B-Raf proto-oncogene, serine/threonine kinase (BRAF) V600 mutation positive to apply to all circumstances (not just metastatic or unresectable disease) per National Comprehensive Cancer Network (NCCN)
- For mesotheliomas, added option for usage originating from the pericardium or the tunica vaginalis per National Comprehensive Cancer Network (NCCN)
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Buprenorphine Injection (Sublocade, Brixadi) (CP.PHAR.289)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy update includes:
- Added pain management to section III as diagnoses/indication for which coverage is not authorized
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Tisagenlecleucel (Kymriah) (CP.PHAR.361)
| Ambetter
| Policy update includes:
- Per National Comprehensive Cancer Network (NCCN) Compendium for LBCL added off-label use for disease relapsed more than 12 months after completion of first-line therapy and partial response following second-line therapy
- Added the following to Appendix C per updated prescribing information: T cell malignancies have occurred following treatment of hematologic malignancies with BCMA- and CD19- directed genetically modified autologous T cell immunotherapies, including Kymriah. Kymriah is available only through a restricted program under a Risk Evaluation and Mitigation Strategy (REMS) called the Kymriah REMS
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Axicabtagene Ciloleucel (Yescarta) (CP.PHAR.362)
| Ambetter
| Policy update includes:
- Per National Comprehensive Cancer Network (NCCN) Compendium for LBCL added off-label use for disease relapsed more than 12 months after completion of first-line therapy and partial response following second-line therapy
- Consolidated extranodal marginal zone lymphoma of the stomach with gastric mucosa-associated lymphoid tissue (MALT) lymphoma and extranodal marginal zone lymphoma of nongastric sites with nongastric mucosa-associated lymphoid tissue (MALT) lymphoma as they refer to the same condition
- Added the following to Appendix C per updated prescribing information: T cell malignancies have occurred following treatment of hematologic malignancies with BCMA- and CD19-directed genetically modified autologous T cell immunotherapies, including Yescarta
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Acalabrutinib (Calquence) (CP.PHAR.366)
| Ambetter
| Policy update includes:
- Per National Comprehensive Cancer Network (NCCN) guidelines added use as induction or maintenance therapy or use as pretreatment for chronic lymphocytic leukemia (CLL) / small lymphocytic lymphoma (SLL), for Waldenstrom macroglobulinemia (WM) clarified that Calquence is to be used as a single agent, replaced the terms “Gastric and Nongastric mucosa-associated lymphoid tissue (MALT) lymphoma” with “Extranodal marginal zone lymphoma (MZL) (noncutaneous)” to align with National Comprehensive Cancer Network (NCCN) nomenclature, for Nodal and Extranodal marginal zone lymphoma (MZL) added the requirement for relapsed, refractory, or progressive disease
- Added newly FDA-approved indication for first-line use in mantle cell lymphoma and converted previous accelerated approval for second-line use in mantle cell lymphoma to full approval
- Per National Comprehensive Cancer Network (NCCN) guidelines removed use of Calquence as maintenance therapy for mantle cell lymphoma (category 2B rec)
- Revised use of Calquence as induction therapy for mantle cell lymphoma to specify use in combination with rituximab and only for less aggressive induction therapy (as opposed to aggressive induction therapy which is a category 2B rec)
- Added exclusion for Imbruvica-refractory mantle cell lymphoma with BTK C481S mutations
- Removed the Legacy Wellcare auth duration for initial approval of the mantle cell lymphoma indication and consolidated to the standard Medicaid approval duration of 6 months
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Pemetrexed (Alimta, Pemfexy, Axtle) (CP.PHAR.368)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy update includes:
- Added Commercial line of business
- For cervical cancer, removed hematologist as prescriber option
- Added off-label indications for vaginal cancer and non-nasopharyngeal cancers per National Comprehensive Cancer Network (NCCN)
- For continued therapy revised language from “has had at least one dose in the last 90 days” to our standard language of “received this medication for at least 30 days”
- Updated HCPCS code descriptions for [J9297 and J9323]
- Added newly approved Axtle to the policy
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Triamcinolone ER Injection (Zilretta) (CP.PHAR.371)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy update includes:
- Added requirement that member is not receiving re-treatment of knee(s) previously treated with Zilretta
- Clarified approval duration for one dose per knee lifetime
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Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Mycapssa) (CP.PHAR.40)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy update includes:
- For Sandostatin, added must use generic octreoide language to continued therapy
- For Sandostatin LAR, added must use generic octrotide language, if available to both initial and continued therapy
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Brolucizumab-dbll (Beovu) (CP.PHAR.445)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy update includes:
- Revised initial approval duration to 6 months for all indications
- Revised initial criteria maximum dosage to include dosing schedule after loading doses
- Revised continued therapy to only apply to requests for dose increase
- In Appendix B per Clinical Pharmacology, updated dosing regimens and clarified off-label indications
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Selumetinib (Koselugo) (CP.PHAR.464)
| Ambetter
| Policy update includes:
- For all indications, added weight-based limitation (25 mg/m2) to max dose requirement
- For off-label National Comprehensive Cancer Network (NCCN) compendium recommended indications, updated the following per National Comprehensive Cancer Network (NCCN): added pleomorphic xanthoastrocytoma (PXA) and neurofibromatosis type 1 (NF-1) mutated circumscribed glioma as coverable diagnoses
- Specified that B-Raf proto-oncogene, serine/threonine kinase (BRAF) fusion or B-Raf proto-oncogene, serine/threonine kinase (BRAF) V600E activating mutation applies only to circumscribed glioma and that Langerhans cell histiocytosis must be mitogen-activated protein (MAP) kinase positive or have no detectable/actionable mutation unless testing is not available
- Added that Koselugo must be prescribed as a single agent
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Zanubrutinib (Brukinsa) (CP.PHAR.467)
| Ambetter
| Policy update includes:
- For mantle cell lymphoma (MCL), added option to be prescribed in combination with Gazyva and Venclexta
- For Waldenstrom macroglobulinemia (WM)/ lymphoplasmacytic lymphoma (LPL), added criterion prescribed as a single agent or in combination with rituximab
- For chronic lymphocytic leukemia (CLL) / small lymphocytic lymphoma (SLL), added option to be prescribed with Tevimbra® for histolotic (Richter) transformation to difusse large B-cell lymphoma
- For hairy cell leukemia, added criterion that disease is relapsed or refractory per National Comprehensive Cancer Network (NCCN)
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Efgartigimod Alfa-fcab, Efgartigimod/Hyaluronidase-qvfc (Vyvgart, Vyvgart Hytrulo) (CP.PHAR.555)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy update includes:
- For generalized myasthenia gravis, added exclusion for concurrent therapy with Bkemv, Epysqli, Zilbrysq, and an neonatal Fc receptor (FcRn) antagonist
- For chronic inflammatory demyelinating polyneuropathy, added exclusion for concurrent therapy with a complement inhibitor or fcrn antagonist
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Asciminib (Scemblix) (CP.PHAR.565)
| Ambetter
| Policy update includes:
- Added criteria for off-label use for chronic myeloid leukemia (CML) in accelerated phase (AP), per National Comprehensive Cancer Network (NCCN) guidelines
- Added exclusion against use in members with the M244V mutation per National Comprehensive Cancer Network (NCCN) guidelines
- Added new Food and Drug Administration (FDA)-approved indication for newly diagnosed Ph+ chronic myeloid leukemia in chronic phase.
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Denosumab (Prolia, Xgeva), Denosumab-bbdz (Jubbonti, Wyost) (CP.PHAR.58)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy update includes:
- Per updated prescribing information for Prolia and Jubbonti added boxed warnings for severe hypocalcemia in patients with advanced kidney disease
- For prostate and breast cancer added requirement that member does not have bone metastasis
- For giant cell tumor of bone localized disease removed option for combination use with interferon alfa per National Comprehensive Cancer Network (NCCN)
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Zoledronic Acid (Reclast) (CP.PHAR.59)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy update includes:
- For brand Reclast requests added redirection to generic
- For initial requests for oncology indications other than prostate and breast cancer, added clarification that request is for zoledronic acid 4 mg/5 ml or 4 mg/100 ml (formerly Zometa)
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Exagamglogene Autotemcel (Casgevy) (CP.PHAR.603)
| Ambetter
| Policy update includes:
- For both sickle cell disease and transfusion dependent β-thalassemia indications, added criterion for documentation of member’s body weight for verification of weight-based dose
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Tremelimumab-actl (Imjudo) (CP.PHAR.612)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy update includes:
- Per National Comprehensive Cancer Network (NCCN) compendium– for non-small cell lung cancer (NSCLC), added recommended uses for present and negative actionable molecular biomarkers
- Revised National Comprehensive Cancer Network (NCCN) recommended uses section to Gastric, Esophageal, and Esophagogastric Junction Cancer, added requirement that disease is microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR), and added provider attestation that member is medically fit for surgery
- Clarified prior authorization may be required for durvalumab
- Revised Commercial continued approval duration from 12 months to standard duration for injectables, 6 months or to the member’s renewal date, whichever is longer
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Lovotibeglogene Autotemcel (Lyfgenia) (CP.PHAR.627)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy update includes:
- Added criterion for documentation of member’s body weight for verification of weight-based dose
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Birch Triterpenes (Filsuvez) (CP.PHAR.669)
| Ambetter
| Policy update includes:
- For initial approval criteria, added “member does not have current evidence or history of squamous cell carcinoma in the area that will undergo treatment” per competitor analysis and EASE study trial design
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Vemurafenib (Zelboraf) (CP.PHAR.91)
| Ambetter
| Policy update includes:
- Per National Comprehensive Cancer Network (NCCN) guidelines added coverage for neuroglioma and glioneuronal tumor as category 2A-supported indications, updated the types of gliomas to circumscribed gliomas and H3-mutated high-grade glioma, removed coverage of the following conditions as not National Comprehensive Cancer Network (NCCN)-supported (oligodendroglioma, astrocytoma), removed coverage of the following conditions that have category 2B recs (thyroid carcinoma, brain metastases)
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Risedronate (Actonel, Atelvia) (CP.PMN.100)
| Ambetter
| Policy update includes:
- Added generic redirection to continuation of therapy requests
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Lasmiditan (Reyvow) (CP.PMN.218)
| Ambetter
| Policy update includes:
- For requests for quantities greater than two doses per month modified to require both specialist prescribing and use of prophylactic therapy to align with criteria requirements of other acute migraine therapy
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CNS Stimulants (CP.PMN.92)
| Ambetter
| Policy update includes:
- Removed Adzenys ER from criteria as drug has been discontinued
- For Adhansia XR, removed discontinued strengths [25 mg, 45 mg, 55 mg, 70 mg, 80 mg]
- Updated Adhansia XR quantity limit to 3 tablets per day
- For Adzenys XR-ODT, split dosing based on 6 to 12 years and > 13 years
- Updated Vyvanse in Appendix B as “lisdexamfetamine (Vyvanse)” to reflect generic availability
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Ivabradine (Corlanor) (CP.PMN.70)
| Ambetter
| Policy updates include:
- Updated Section V to include specific weight-based maximum doses for pediatric patients
- Revised policy/criteria section to also include generic ivabradine and added redirection to generic for brand requests per formulary status
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Nemolizumab-ilto (Nemluvio) (CP.PHAR.703)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- For prurigo nodularis initial criteria, added redirection to Dupixent
- Added criteria for new indication of atopic dermatitis
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Adalimumab (Humira) Humira Biosimilars (CP.PHAR.242)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Added adalimumab-aacf and adalimumab-bwwd to criteria
- For hidradenitis suppurativa, added adalimumab-aacf, adalimumab-adbm, adalimumab-bwwd, and adalimumab-ryvk to age greater than 18 years criteria
- For ulcerative colitis and uveitis, added adalimumab-aacf, adalimumab-bwwd, and adalimumab-ryvk to age greater than 18 years criteria
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Ustekinumab (Stelara and biosimilars) (CP.PHAR.264)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Added newly approved biosimilar Yesintek to criteria
- For Pyzchiva, added new dosage formulation [single-dose vial for subcutaneous injection 45 mg/0.5 ml]
- For psoriasis and psoriatic arthritis, added Pyzchiva to “weight less than 60 kg: 0.75 mg/kg per dose” pediatric dosing criteria
- For Wezlana, added new dosage formulation [single-dose prefilled autoinjector (confipen) 45 mg/0.5 ml, 90 mg/ml]
- Added newly approved biosimilar Steqeyma to criteria
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Lofexidine (Lucemyra) (CP.PMN.152)
| Ambetter
| Policy updates include:
- Added redirection to generic lofexidine
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Insulin detemir (Levemir) (HIM.PA.171)
| Ambetter
| Policy updates include:
- Added disclaimer that Novo Nordisk discontinued Levemir products
- Added requirement for provider attestation acknowledging the discontinuation of Levemir products
- Added Appendix E regarding discontinuation of Levemir products
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Leuprolide Acetate (Eligard, Fensolvi, Lupron Depot, Lupron Depot-Ped), Leuprolide mesylate (Camcevi) (CP.PCH.53)
| Ambetter
| Policy updates include:
- For gender dysphoria and gender transition, added requirement for provider attestation of understanding current State regulations regarding transgender-related health care and such care is coverable under the State regulations, added to Appendix D link and notation that the Movement Advancement Project can be referenced to confirm transgender-related health care is coverable under the State regulations
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Goserelin Acetate (Zoladex) (CP.PHAR.171)
| Ambetter
| Policy updates include:
- For gender dysphoria and gender transition, added requirement for provider attestation of understanding current State regulations regarding transgender-related health care and such care is coverable under the State regulations, added to Appendix D link and notation that the Movement Advancement Project can be referenced to confirm transgender-related health care is coverable under the State regulations
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Histrelin Acetate (Vantas, Supprelin LA) (CP.PHAR.172)
| Ambetter
| Policy updates include:
- For gender dysphoria and gender transition, added requirement for provider attestation of understanding current State regulations regarding transgender-related health care and such care is coverable under the State regulations, added to Appendix D link and notation that the Movement Advancement Project can be referenced to confirm transgender-related health care is coverable under the State regulations
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Leuprolide Acetate (Eligard, Fensolvi, Lupron Depot, Lupron Depot-Ped), Leuprolide mesylate (Camcevi) (CP.PHAR.173)
| Ambetter
| Policy updates include:
- For gender dysphoria and gender transition, added requirement for provider attestation of understanding current State regulations regarding transgender-related health care and such care is coverable under the State regulations, added to Appendix D link and notation that the Movement Advancement Project can be referenced to confirm transgender-related health care is coverable under the State regulations
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Nafarelin Acetate (Synarel) (CP.PHAR.174)
| Ambetter
| Policy updates include:
- For gender dysphoria and gender transition, added requirement for provider attestation of understanding current State regulations regarding transgender-related health care and such care is coverable under the State regulations, added to Appendix D link and notation that the Movement Advancement Project can be referenced to confirm transgender-related health care is coverable under the State regulations
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Triptorelin Pamoate (Trelstar, Triptodur) (CP.PHAR.175)
| Ambetter
| Policy updates include:
- For gender dysphoria and gender transition, added requirement for provider attestation of understanding current State regulations regarding transgender-related health care and such care is coverable under the State regulations, added to Appendix D link and notation that the Movement Advancement Project can be referenced to confirm transgender-related health care is coverable under the State regulations
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Testosterone (Testopel, Jatenzo, Kyzatrex, Tlando) (CP.PHAR.354)
| Ambetter
| Policy updates include:
- For gender dysphoria and gender transition, added requirement for provider attestation of understanding current State regulations regarding transgender-related health care and such care is coverable under the State regulations, added to Appendix D link and notation that the Movement Advancement Project can be referenced to confirm transgender-related health care is coverable under the State regulations
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Testosterone (Androderm) (HIM.PA.87)
| Ambetter
| Policy updates include:
- For gender dysphoria and gender transition, added requirement for provider attestation of understanding current State regulations regarding transgender-related health care and such care is coverable under the State regulations, added to Appendix D link and notation that the Movement Advancement Project can be referenced to confirm transgender-related health care is coverable under the State regulations
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