Effective November 1, 2024: Pharmacy and Biopharmacy Policies

POLICY

APPLICABLE PRODUCTS

NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS

Ruxolitinib (Jakafi, Opzelura) (CP.PHAR.98)

Ambetter

Policy updates include:

• For graft-versus-host disease, revised tablet quantity limit to 2 due to twice daily regimen

Aflibercept (Eylea, Eylea HD, Opuviz, Yesafili, Ahzantive, Enzeevu, Pavblu) (CP.PHAR.184)

Ambetter

Policy updates include:

• Added new Eylea biosimilars Enzeevu and Pavblu; expanded retinopathy of prematurity indication criteria to also allow use of the biosimilars – Opuviz, Yesafili, Ahzantive, Enzeevu, and Pavblu

Adalimumab (Humira), Adalimumab-afzb (Abrilada), Adalimumab-atto (Amjevita), Adalimumab-adbm (Cyltezo), Adalimumab-bwwd (Hadlima), Adalimumab-fkjp (Hulio), Adalimumab-adaz (Hyrimoz), Adalimumab-aacf (Idacio), Adalimumab-ryvk (Simlandi), Adalimumab-aaty (Yuflyma), Adalimumab-aqvh (Yusimry) (CP.PHAR.242)

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

Policy updates include:

• For Simlandi, added new prefilled syringe formulation and strengths [20 mg/0.2 mL, 40 mg/0.4 mL, 80 mg/0.8 mL]
• For section V, added Simlandi pediatric dose for polyarticular juvenile idiopathic arthritis [15 kg to less than 30 kg: 20 mg every other week] and pediatric dose for CD [17 kg to less than 40 kg: 80 mg subcutaneous on Day 1, 40 mg subcutaneous on Day 15, then 20 mg subcutaneous every other week starting on Day 29]
• For Appendix K, added preferred Simlandi NDCs [51759-0386-22, 51759-0412-22, 51759-0386-22]

Ixekizumab (Taltz) (CP.PHAR.257)

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

Policy updates include:

• Added new strengths for single-dose prefilled syringe [20 mg/0.25 mL, 40 mg/0.5 mL]

Paliperidone inj (Invega Sustenna, Invega Trinza, Invega Hafyera, Erzofri) (CP.PHAR.291)

Ambetter

Policy updates include:

• Added newly approved Erzofri to the policy

Durvalumab (Imfinzi) (CP.PHAR.339)

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

Policy updates include:

• Added criteria for newly Food and Drug Administration (FDA)-approved indication for use as neoadjuvant/adjuvant therapy in resectable non-small cell lung cancer
• 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

Corticosteroids for Ophthalmic Injection (Dextenza, Iluvien, Ozurdex, Retisert, Xipere, Yutiq) (CP.PHAR.385)

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

Policy updates include:

• For diabetic macular edema, macular edema, and uveitis, removed required step through of intravitreal steroid injections due to lack of commercial availability (Triesence is the only intravitreal steroid injection on market, and it is currently on shortage without a known resolution date)

Fibrinogen concentrate (human) (Fibryga, RiaSTAP) (CP.PHAR.526)

Ambetter

Policy updates include:

• Updated Fibryga with new Food and Drug Administration (FDA) indication for acquired fibrinogen deficiency

Insulin Delivery Systems (V-Go, Omnipod, InPen) (CP.PHAR.534)

Ambetter

Policy updates include:

• For Omnipod 5, updated the Food and Drug Administration (FDA) Approved Indication section to reflect newly approved use of the SmartAdjust technology in adults with type 2 diabetes

Dostarlimab-gxly (Jemperli) (CP.PHAR.540)

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

Policy updates include:

• For endometrial carcinoma, updated Food and Drug Administration (FDA) approved indication to remove requirement for disease to be mismatch repair deficient (dMMR)/ microsatellite instability-high (MSI-H) when prescribed in combination with carboplatin and paclitaxel per expanded label, and clarified in criteria that stage III-IV is advanced

Amivantamab-vmjw (Rybrevant) (CP.PHAR.544)

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

Policy updates include:

• Added criteria for new indication for non-small cell lung cancer in combination with Lazcluze
• For Rebervant prescribed as subsequent therapy after Tagrisso, exon 19 insertion mutation was removed, and the sensitizing epidermal growth factor receptor                                                 mutations were revised according to National Comprehensive Cancer Network (NCCN) exon characterization

Furosemide (Furoscix) (CP.PHAR.608)

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

Policy updates include:

• Removed specification of New York Heart Association (NYHA) Class II or Class III from criteria per expanded Food and Drug Administration (FDA)-approved indication
• Removed ascites from contraindications and revised dosage strength from 80 mg/mL to 80 mg/10 mL

Nalmefene (Opvee, Zurnai) (CP.PHAR.638)

Ambetter

Policy updates include:

• Added newly approved Zurnai to the policy

Iptacopan (Fabhalta) (CP.PHAR.656)

Ambetter

Policy updates include:

• Added newly approved Food and Drug Administration (FDA) indication of immunoglobulin A nephropathy

Carbidopa-Levodopa ER Capsules (Crexont, Rytary), Enteral Suspension (Duopa), IR Tablets (Dhivy) (CP.PMN.238)

Ambetter

Policy updates include:

• Added newly approved Crexont to the policy