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Effective May 1, 2025: Pharmacy and Biopharmacy Policies

Date: 02/25/25

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 May 1, 2025, at 12:00AM.

POLICYAPPLICABLE PRODUCTSNEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS
Tafamidis (Vyndaqel, Vyndamax) (CP.PHAR.432)Ambetter

Policy updates include:

  • For initial approval criteria and continued therapy, added Attruby to list of excluded agents for concurrent use
Sacituzumab govitecan-hziy (Trodelvy) (CP.PHAR.475)Ambetter

Policy updates include:

  • Updated to include withdrawal of previously Food and Drug Administration (FDA)-approved indication for urothelial cancer and changed to off-label as the use remains National Comprehensive Cancer Network (NCCN) supported
  • Added provider attestation criterion acknowledging FDA withdrawal
  • Added withdrawal information in Appendix D
Delandistrogene moxeparvovec-rokl (Elevidys) (CP.PHAR.593)Ambetter

Policy updates include:

  • Added requirement for current documentation (within the last 90 days) of member’s body weight (in kg)
Encorafenib (Braftovi) (CP.PHAR.127)Ambetter

Policy updates include:

  • Added newly Food and Drug Administration (FDA)-approved use in metastatic colorectal cancer in combination with cetuximab and mFOLFOX6.
Durvalumab (Imfinzi) (CP.PHAR.339)Ambetter

Policy updates include:

  • Added criteria for newly Food and Drug Administration (FDA)-approved indication of limited-stage small cell lung cancer
Tislelizumab-jsgr (Tevimbra) (CP.PHAR.687)Ambetter

Policy updates include:

  • Updated criteria to include new indication for gastric or gastroesophageal junction adenocarcinoma
Tapinarof (Vtama) (CP.PMN.283)Ambetter

Policy updates include:

  • Added newly approved atopic dermatitis indication to criteria.
Hydroxyurea (Siklos, Xromi) (CP.PMN.193)Ambetter

Policy updates include:

  • Revised Xromi indication for pediatric extension up to 18 years of age
Overactive Bladder Agents (CP.PMN.198)Ambetter

Policy updates include:•

  • For Gemtesa added additional indication for overactive bladder in adult males on pharmacological therapy for benign prostatic hyperplasia per updated prescribing information.


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.