POLICY
| APPLICABLE PRODUCTS
| NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS
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Brentuximab Vedotin (Adcetris) (CP.PHAR.303)
| Ambetter
| Policy updates include:- Added criteria for new Food and Drug Administration (FDA)-approved indication of relapsed or refractory large B-cell lymphoma in adult patients – added criterion that disease is relapsed or refractory, added option that member is not a candidate for chimeric antigen receptor (CAR) T-cell therapy
- Per National Comprehensive Cancer Network (NCCN) for B-cell lymphomas – added pathway for off-label use as a single agent or in combination with rituximab or nivolumab, clarified use in human immunodeficiency virus (HIV)-related B-cell lymphoma and post-transplant lymphoproliferative disorder are off-label indications
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Apomorphine (Apokyn, Apokyn NXT, Onapgo) (CP.PHAR.488)
| Ambetter
| Policy updates include:- Added new formulations Apokyn NXT and Onapgo to policy
- Added generic apomorphine to policy requiring prior authorization
- For Apokyn or Apokyn NXT, added must use generic apomorphine language
- Revised “prescribed concurrently with an anti-Parkinson agent” to “prescribed concurrently with levodopa/carbidopa”
- Added requirement for trial and failure of at least two anti-Parkinson agents from different therapeutic classes, unless clinically significant adverse events are experienced or all are contraindicated
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Sotorasib (Lumakras) (CP.PHAR.549)
| Ambetter
| Policy updates include:- Added new Food and Drug Administration (FDA)-approved indication of colorectal cancer and removed requirement for previous use of a fluoropyrimidine- (e.g., 5-fluorouracil, capecitabine), oxaliplatin-, and irinotecan-containing chemotherapy per National Comprehensive Cancer Network (NCCN) and as Appendix B now lists previous colorectal cancer regimens
- Removed colon, appendiceal, and rectal cancers from National Comprehensive Cancer Network (NCCN)-recommended off-label uses section as these are now encompassed within the colorectal cancer section
- For National Comprehensive Cancer Network (NCCN)-recommended off-label uses, added requirements for positive KRAS G12C mutation, previous therapy, and Lumakras monotherapy use per National Comprehensive Cancer Network (NCCN) Compendium
- For ampullary adenocarcinoma, added requirement for disease progression per National Comprehensive Cancer Network (NCCN)
- For small bowel adenocarcinoma, added requirement for advanced or metastatic disease per National Comprehensive Cancer Network (NCCN)
- For pancreatic adenocarcinoma, added requirement for locally advanced, recurrent, or metastatic disease
- For non-small cell lung cancer, added monotherapy requirement
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Ranibizumab (Lucentis, Susvimo), Lucentis Biosimilars (CP.PHAR.186)
| Ambetter
| Policy updates include:
- For Susvimo, updated Food and Drug Administration (FDA) indication to include diabetic macular edema and clarified maximum dose is 2 mg (one 100 mg/mL vial) per 6 months
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Buprenorphine (Sublocade, Brixadi) (CP.PHAR.289)
| Ambetter
| Policy updates include:
- For Sublocade, updated criteria to include Food and Drug Administration (FDA) approved rapid initiation protocol (previously required 7 days of transmucosal buprenorphine)
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Panitumumab (Vectibix) (CP.PHAR.321)
| Ambetter
| Policy updates include:- Added new Food and Drug Administration (FDA)-approved indication of Kirsten rat sarcoma 2 viral oncogene homologue (KRAS) G12C-mutated colorectal cancer
- Removed prior therapy requirement when prescribed for BRAF V600E mutation positive in combination with Braftovi and added clarification that regimen may be “with or without fluorouracil, leucovorin, oxaliplatin (FOLFOX)” per National Comprehensive Cancer Network (NCCN)
- Modified requirement for left-sided colon cancer to also apply to unresectable metachronous metastases per National Comprehensive Cancer Network (NCCN)
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Denosumab (Prolia, Xgeva), Denosumab-bbdz (Jubbonti, Wyost), Denosumab-dssb (Ospomyv, Xbryk), Denosumab-bmwo (Stoboclo, Osenvelt) (CP.PHAR.58)
| Ambetter
| Policy updates include:
- Added new biosimilars denosumab-dssb, Osenvelt, Ospomyv, Stoboclo, and Xbryk to criteria
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Avacincaptad pegol (Izervay) (CP.PHAR.641)
| Ambetter
| Policy updates include:- Per updated Food and Drug Administration (FDA) label removal of the one-year duration limit for the treatment of geographic atrophy, removed continued authorization criterion for treatment exceeding 12 months
- Increased Medicaid/Ambetter continued approval duration from 6 months to 12 months for this chronic condition
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Eculizumab (Soliris, Bkemv, Epysqli) (CP.PHAR.97)
| Ambetter
| Policy updates include:- Updated Food and Drug Administration (FDA) approved indication for Soliris to include generalized myasthenia gravis 6 years old pediatric expansion
- For atypical hemolytic uremic syndrome, generalized myasthenia gravis, and neuromyelitis optica spectrum disorder, updated dose maximum and added asterisk stating additional doses of eculizumab may be approved if the member is receiving plasmapheresis, plasma exchange, fresh frozen plasma, or intravenous immunoglobulin
- Added Appendix E to provide supplemental dosing information
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Esketamine (Spravato) (CP.PMN.199)
| Ambetter
| Policy updates include:- Updated treatment-resistant depression indication to include monotherapy option
- For treatment-resistant depression, revised initial approval maximum to allow for 24 nasal spray devices
- For treatment-resistant depression initial therapy, removed requirement for stabilization and future combination use with an oral antidepressant
- For treatment-resistant depression continued therapy, removed requirement for use in combination with an oral antidepressant
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Chenodiol (Chenodal, Ctexli) (CP.PMN.239)
| Ambetter
| Policy updates include:- Added criteria for Ctexli, a newly Food and Drug Administration (FDA)-approved brand for the indication of cerebrotendinous xanthomatosis
- For radiolucent gallstones, added criterion requiring request is for Chenodal
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DPP-4 inhibitors (HIM.PA.58)
| Ambetter
| Policy updates include:
- Added newly approved Brynovin to criteria
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Compounded Medications (CP.PMN.280)
| Ambetter
| Policy updates include:
- Added criterion to check benefit master grid to ensure coverability for Medicaid members
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