Effective Tuesday August 1, 2023: Pharmacy and Biopharmacy Policies

Ibrutinib (Imbruvica) (CP.PHAR.126)

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

Policy updates include:

• Removed previously approved FDA indications for MCL and MZL and converted to NCCN supported off-label indications

Sildenafil (Revatio, Liqrev) (CP.PHAR.197)

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

Policy updates include:

• Added new oral suspension formulation Liqrev to policy

Adalimumab (Humira) Humira Biosimilars (CP.PHAR.242)

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

Policy updates include:

• For Cyltezo, added new dosage form (single-dose prefilled pen 40 mg/0.8 mL) and single-dose prefilled syringe 10 mg/0.2 mL to policy
• Added Yuflyma biosimilar to policy
• Added HCPCS codes [Q5131] and [C9399]

Secukinumab (Cosentyx) (CP.PHAR.261)

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

Policy updates include:

• Added new dosage forms (UnoReady Pen and 300 mg/2 mL dose of pre-filled syringe) to policy

Teprotumumab (Tepezza) (CP.PHAR.465)

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

Policy updates include:

• Updated indication extension for TED treatment regardless of TED activity or duration,
• Removed the initial therapy CAS criterion
• Removed positive response criteria of proptosis and CAS reduction from continued therapy as full lifetime course of therapy is within 6 month authorization and proptosis/CAS reduction are endpoints assessed at 24 weeks (after full duration of therapy)

Human Growth Hormone (Somapacitan, Somatropin) (CP.PHAR.517)

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

Policy updates include:

• Added pediatric extension for GF due to GHD and new 15 mg/1.5 mL strength
• ·        For pediatric GHD criteria set added Sogroya specific age limit and dosing

Atogepant (Qulipta) (CP.PHAR.566)

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

Policy updates include:

• Policy updated to incorporate expanded indication for preventive treatment of chronic migraine.

Inhaled asthma and COPD agents (CP.PMN.259)

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

Policy updates include:

• Added dosage form Symbicort Aerosphere to policy with redirection to generic Symbicort per SDC and prior clinical guidance
• Updated Breo Ellipta per prescribing information for pediatric extension down to 5 years of age and older
• Clarified applicable redirections based on age
• Added new 50/25 mcg/actuation strength form
• Corrected maximum dose for Bevespi Aerosphere from 2 inhalations/day to 4 inhalations/day per dosing regimen (2 inhalations BID)

Cyclosporine ophthalmic emulsion (Cequa, Restasis, Verkazia, Vevye) (CP.PMN.48)

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

Policy updates include:

• Added new dosage form Vevye

Step Therapy (HIM.PA.109)

Ambetter

Policy updates include:

• Added celecoxib to policy requiring step through meloxicam or generic NSAID or current use of corticosteroid or anticoagulant.

Cariprazine (Vraylar) (CP.PMN.91)

Ambetter

Policy updates include:

• Addition of dementia-related psychosis to section III for diagnoses/indications for which coverage is not authorized
• Added new indication for use as adjunctive treatment in major depressive disorder