POLICY

APPLICABLE PRODUCTS

NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS

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

Ambetter

Policy updates include:

· For atopic dermatitis, updated criteria with pediatric extension to include ages 2 years and older

Immune Globulins (CP.PHAR.103)

Ambetter

Policy updates include:

· For continued therapy, added language “(or health plan-preferred* immune globulin product)” to continue its usage, unless medical justification supports necessity for immune globulin product switch

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

Ambetter

Policy updates include:

· Added new Eylea biosimilar Eydenzelt

Factor VIII-von Willebrand (Alphanate, Humate-P, Vonvendi, Wilate) (CP.PHAR.216)

Ambetter

Policy updates include:

· For Vonvendi, updated with pediatric extension for on-demand treatment of bleeding episodes, control of bleeding episodes, and perioperative management of bleeding, as well as with expansion to types 1 and 2 von Willebrand disease for routine prophylaxis

Pembrolizumab, Pembrolizumab Berahyaluronidase alfa-pmph (Keytruda, Keytruda Qlex) (CP.PHAR.322)

Ambetter

Policy updates include:

· Added new subcutaneous formulation Keytruda Qlex to policy

· For Keytruda, converted Food and Drug Administration (FDA) approved indication for 400 mg every 6 week dosing regimen in adults with classical Hodgkin lymphoma and primary mediastinal large B-cell lymphoma to full approval

Letermovir (Prevymis) (CP.PHAR.367)

Ambetter

Policy updates include:

· Added criterion Prevymis must be initiated within 7 days post kidney transplant and 28 days post hematopoietic stem cell transplant

Bortezomib (Boruzu, Velcade) (CP.PHAR.410)

Ambetter

Policy updates include:

· Added new formulation Boruzu

· Removed “if available” from generic bortezomib redirection as it is currently available

Selumetinib (Koselugo) (CP.PHAR.464)

Ambetter

Policy updates include:

· Revised criteria to reflect pediatric extension from age 2 years and older to age 1 year and older and added new dosage form (oral granules) with requirement for body surface area at least 0.4 m2

Lisocabtagene maraleucel (Breyanzi) (CP.PHAR.483)

Ambetter

Policy updates include:

· Corrected follicular lymphoma and mantle cell lymphoma maximum dose from 100 to 110 x 106 chimeric antigen receptor (CAR)-positive viable T cells

Beremagene Geperpavec (Vyjuvek) (CP.PHAR.592)

Ambetter

Policy updates include:

· Removed lower age limit of 6 months and modified maximum dose from 1.6 and 3.2 x 109 PFU per week to 2 and 4 x 109 PFU per week per updated labeling

· Added administration information allowing application by patient or caregiver per updated instructions for use

Bedaquiline (Sirturo) (CP.PMN.212)

Ambetter

Policy updates include:

· Updated to include pediatric extension down to 2 years of age and weighing at least 8 kg for multi-drug resistant tuberculosis without pretomanid per updated prescribing information

Opioid Analgesics (HIM.PA.139)

Ambetter

Policy updates include:

· Added criterion that request does not exceed health plan-approved quantity limit, if applicable to all indications

Human Growth Hormone (Somapacitan, Somatrogon, Somatropin, Lonapegsomatropin-tcgd) (HIM.PA.161)

Ambetter

Policy updates include:

· For Skytrofa, added new indication for replacement of endogenous growth hormone in adults with growth hormone deficiency and added new cartridge strengths (0.7 mg, 1.4 mg, 1.8 mg, 2.1 mg, 2.5 mg)

Evinacumab-dgnb (Evkeeza) (HIM.PA.166)

Ambetter

Policy updates include:

· Updated Food and Drug Administration (FDA) approved pediatric extension from at least 5 years to at least 1 years for homozygous familial hypercholesterolemia