POLICY
| APPLICABLE PRODUCTS
| NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS
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Brentuximab Vedotin (Adcetris) (CP.PHAR.303)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Added criteria for new Food and Drug Administration (FDA)-approved indication of relapsed or refractory large B-cell lymphoma in adult patients – added criterion that disease is relapsed or refractory, added option that member is not a candidate for chimeric antigen receptor (CAR) T-cell therapy
- Per National Comprehensive Cancer Network (NCCN) for B-cell lymphomas – added pathway for off-label use as a single agent or in combination with rituximab or nivolumab, clarified use in human immunodeficiency virus (HIV)-related B-cell lymphoma and post-transplant lymphoproliferative disorder are off-label indications
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Apomorphine (Apokyn, Apokyn NXT, Onapgo) (CP.PHAR.488)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Added new formulations Apokyn NXT and Onapgo to policy
- Added generic apomorphine to policy requiring prior authorization
- For Apokyn or Apokyn NXT, added must use generic apomorphine language
- Revised “prescribed concurrently with an anti-Parkinson agent” to “prescribed concurrently with levodopa/carbidopa”
- Added requirement for trial and failure of at least two anti-Parkinson agents from different therapeutic classes, unless clinically significant adverse events are experienced or all are contraindicated
|
Sotorasib (Lumakras) (CP.PHAR.549)
| Ambetter
| Policy updates include:
- Added new Food and Drug Administration (FDA)-approved indication of colorectal cancer and removed requirement for previous use of a fluoropyrimidine- (e.g., 5-fluorouracil, capecitabine), oxaliplatin-, and irinotecan-containing chemotherapy per National Comprehensive Cancer Network (NCCN) and as Appendix B now lists previous colorectal cancer regimens
- Removed colon, appendiceal, and rectal cancers from National Comprehensive Cancer Network (NCCN)-recommended off-label uses section as these are now encompassed within the colorectal cancer section
- For National Comprehensive Cancer Network (NCCN)-recommended off-label uses, added requirements for positive KRAS G12C mutation, previous therapy, and Lumakras monotherapy use per National Comprehensive Cancer Network (NCCN) Compendium
- For ampullary adenocarcinoma, added requirement for disease progression per National Comprehensive Cancer Network (NCCN)
- For small bowel adenocarcinoma, added requirement for advanced or metastatic disease per National Comprehensive Cancer Network (NCCN)
- For pancreatic adenocarcinoma, added requirement for locally advanced, recurrent, or metastatic disease
- For non-small cell lung cancer, added monotherapy requirement
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