News
Effective December 1, 2024: Pharmacy and Biopharmacy Policies
Date:
10/04/24
Magnolia Health Plan has added, updated or retired certain pharmacy and biopharmacy policies to ensure medical necessity review criteria is current and appropriate for members and the scope of services provided. As a result, the following policies are effective on December 1, 2024, at 12:00AM.
| POLICY | APPLICABLE PRODUCTS | NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS |
|---|
| Cerliponase alfa (Brineura) (CP.PHAR.338) | Ambetter | Policy updates include:
- Updated criteria to reflect the newly Food and Drug Administration (FDA)-approved indication expansion to include symptomatic and presymptomatic patients younger than 3 years of age, including the following changes: removed any references to “late infantile” disease, replaced the age requirement with the 2.5 kg minimum weight requirement per dosing recommendations in the Prescribing Information
- Added the Boxed Warning re: hypersensitivity reactions including anaphylaxis
|
| Asciminib (Scemblix) (CP.PHAR.565) | Ambetter | Policy updates include:
- Added new 100 mg tablet strength
|
| Cabotegravir, Cabotegravir-rilpivirine (Apretude, Cabenuva) (CP.PHAR.573) | Ambetter | Policy updates include:
- For PrEP indication, added criterion to generic Truvada redirection to allow bypass if member has history of non-adherence to oral PrEP therapy.
|
| Faricimab (Vabysmo) (CP.PHAR.581) | Ambetter | Policy updates include:
- Added newly approved prefilled syringe formulation.
|
| Belimumab (Benlysta) (CP.PHAR.88) | Ambetter | Policy updates include:
- Updated systemic lupus erythematosus dosing for subcutaneous to reflect expanded indication to patients 5+ years old
|
| Non-Calcium Phosphate Binders (Auryxia, Fosrenol, Renagel, Renvela, Velphoro) (CP.PMN.04) | Ambetter | Policy updates include:
- For Velphoro, updated age to ≥ 9 years (previously adults only) to reflect pediatric extension
|
| DPP-4 inhibitors (HIM.PA.58) | Ambetter | Policy updates include:
- Added newly approved Zituvimet XR to criteria
|
| Betaine (Cystadane) (CP.PHAR.143) | Ambetter | Policy updates include:
- For Cystadane requests, added redirection to generic
|
Luspatercept-aamt
(Reblozyl) (CP.PHAR.450) | Ambetter | Policy updates include:
- For myelodysplastic syndromes, revised criterion myelodysplastic syndromes with ring sideroblasts < 15% (or ring sideroblasts < 5% with SFB3B1 mutation) from “failure of erythropoiesis-stimulating agent (ESA) agent unless contraindicated or documentation of current erythropoietin > 500 mU/mL” to “one of the following: response to or ineligible for ESA therapy OR both of the following: documentation of current serum erythropoietin < 500 mU/mL AND failure of Retacrit or if Retacrit is unavailable due to shortage, member must use Epogen” to direct to our preferred ESA agents
- For myelodysplastic syndromes initial approval criteria, added “myelodysplastic syndromes that is very low, low, or intermediate-1 risk as classified by International Prognostic Scoring System - Revised (IPSS-R)” as an option under diagnosis
- For myelodysplastic syndromes initial and continued therapy criteria, added “Reblozyl is not prescribed concurrently with Rytelo.”
|
| Tremelimumab-actl (imjudo) (CP.PHAR.612) | Ambetter | Policy updates include:
- For unresectable hepatocellular carcinoma, revised continued therapy section to not permit re-authorization per package insert
|
To review all policies, please visit Magnolia's Clinical & Payment Policies webpage.
Prior to updates, pharmacy and biopharmacy clinical policies are reviewed and approved by the Pharmacy and Therapeutics (P&T) Committee.
For questions or additional information, please contact Magnolia’s Pharmacy Department at 1-866-912-6285, ext. 66409.
