Effective March 1, 2024: Pharmacy and Biopharmacy Policies

Policy updates include:

• For brand Feraheme requests, added redirection
  to generic. 

• Revised to template redirection language and
  simplified to remove redirection by age
• Revised redirection to Feraheme to instead require generic Feraheme

• For Amjevita, added new strengths for prefilled
  autoinjector 40 mg/0.4 mL, 80 mg/0.8 mL and prefilled syringe 20 mg/0.2 mL, 40
  mg/0.4 mL, 80 mg/0.8 mL in section VI
• For Abrilada, Hulio/ adalimumab-fkjp, Hyrimoz/adalimumab-adaz, and Yusimry , updated FDA approved indications, approval criteria, and dosing in section V to reflect new uveitis indication
• For continued therapy, updated criteria from “member must use one of the following” preferred biosimilars to “member must use all of the following” preferred biosimilars
• For Yuflyma,  added new strengths for auto-injector 80 mg/0.8 mL, prefilled syringe with safety guard 80 mg/0.8 mL, and prefilled syring 20 mg/0.2 mL and 08 mg/0.8 mL and updated Yuflyma pediatric weight base dosing for polyarticular juvenile idiopathic arthritis and Crohn’s disease in section V; 
• For Idacio,  updated FDA approved indications, approval criteria, and dosing in section V to reflect new hidradenitis suppurativa indication Added Tofidence to section III.B. Added HCPCS code [Q5132].

• Revised to template redirection language
• Revised redirection to Feraheme to instead require generic Feraheme.

Policy updates include:

• Added disclaimer about FDA and manufacturer withdrawal
• Added
  requirement for prescriber attestation to all criteria sets
• Added Appendix D
   

Dipeptidyl
Peptidase-4 (DPP-4) Inhibitors (HIM.PA.58)

Policy updates
include:  

• Added newly approved non-preferred Zituvio to
  criteria; for initial approval criteria, specified “preferred sitagliptin-containing product” to clarify redirection applies to preferred products only

• Revised redirection from brand Flovent HFA/Flovent Diskus to instead redirect to fluticasone proprionate HFA (Flovent HFA authorized generic)
• Added Flovent HFA and Advair HFA to policy requiring redirection to authorized generic
• Revised redirection to brand Advair HFA to instead redirect to authorized generic
• For LABA/LAMA revised redirection to Bevespi Aerosphere to instead redirect to Stiolto Respimat
• Added Bevespi Aerosphere to policy with redirection to Anoro Ellipta and Stiolto Respimat
• For AirDuo Digihaler, AirDuo RespiClick, Dulera, updated redirection to include both Breo Ellipta authorized generic and brand Breo Ellipta

Policy updates
include:

• Policy created and adapted from CP.PHAR.125, for
  breast cancer added redirection to Kisqali and Verzenio.

Policy updates
include:

• Removed Ambetter line of business

Policy updates
include:

• Policy created  and adapted from CP.PMN.224 and added redirection to Linzess for irritable bowel syndrome with constipation

• Removed Synjardy and Synjardy XR as prior
  authorization is not required
• Contraindications section revised for Brenzavvy, Invokana, and Steglatro
• Removed Farxiga and Xigduo XR as prior authorization is no longer required
• Added redirection to Farxiga to all indications
• Updated Appendix B with relevant therapeutic alternatives
• Updated Appendix D with literature to support the use of Farxiga, but not Jardiance, in patients with type 2 diabetes mellitus and multiple cardiovascular risk factors

Policy updates include:

• Removed redirection to Vosevi and applied
  Epclusa authorized generic redirection to all requests.

Policy updates include:

• Removed stepwise redirection and applied Epclusa
  authorized generic redirection to all requests

Policy updates include:

• Applied Epclusa authorized generic redirection
  to all requests

Policy updates include:

• Applied Epclusa authorized generic redirection to all requests

Policy updates include:

• Expanded Epclusa authorized generic redirection
  to include states other than Florida

• For Amjevita, added new strengths for prefilled
  autoinjector 40 mg/0.4 mL, 80 mg/0.8 mL and prefilled syringe 20 mg/0.2 mL, 40 mg/0.4 mL, 80 mg/0.8 mL in section VI
• For Abrilada, Hulio/ adalimumab-fkjp, Hyrimoz/adalimumab-adaz, and Yusimry, updated FDA approved indications, approval criteria, and dosing in section V to reflect new UV indication
• For Entyvio, added new dosage forms (prefilled syringe and Entyvio Pen) for subcutaneous injection to sections V and VI
• For section VI, revised Entyvio formulation from “single-use vial” to “lyophilized powder in a single-dose vial for reconstitution for intravenous infusion: 300 mg”
• For Entyvio: for Crohn’s disease, added “request is for intravenous formulation” in initial approval and continued therapy sections
• Added newly approved biosimilar Tofidence to FDA approved indication section, polyarticular juvenile idiopathic arthritis, rheumatoid arthritis, systemic juvenile idiopathic arthritis criteria, and section V
• Tyruko (a Tysabri biosimilar) added to FDA approved indications, approval criteria, and section V to reflect new Crohn’s disease and multiple sclerosis indication
• For Yuflyma, added new strengths for auto-injector 80 mg/0.8 mL, prefilled syringe with safety guard 80 mg/0.8 mL, and prefilled syringe 20 mg/0.2 mL and 08 mg/0.8 mL and updated Yuflyma pediatric weight base dosing for polyarticular juvenile idiopathic arthritis and Crohn’s disease in section V
• For Idacio, updated FDA approved indications, approval criteria, and dosing in section V to reflect new hidradenitis suppurativa indication
• For Cosentyx, added new dosage form single-dose vial 125 mg/ 5 mL for intravenous infusion, added intravenous specific dosing for ankylosing spondylitis, non-radiographic axial spondyloarthritis, and psoriatic arthritis
• For psoriatic arthritis, added newly approved juvenile psoriatic arthritis indication for Enbrel
• Added Tofidence to section III.B; added HCPCS code [Q5132]
• For Crohn’s disease, plaque psoriasis, psoriatic arthritis, ulcerative colitis, and continued therapy, removed criteria “for Stelara: if request is through the pharmacy benefit for 45 mg/0.5 mL vial formulation, member must use Stelara pre-filled syringe”
• For plaque psoriasis, added Bimzelx to criteria
• For Crohn’s disease and ulcerative colitis, added Zymfentra to criteria
• For ulcerative colitis, added Velsipity to criteria
• For ulcerative colitis, added Omvoh to criteria