Selexipag (Uptravi) (CP.PHAR.196)

Ambetter/ICHRA

Policy updates include:

· Updated to reflect pediatric extension for pulmonary arterial hypertension and added new 100 mcg and 150 mcg tablet dosage strengths

Trabectedin (Yondelis, Evdi) (CP.PHAR.204)

Ambetter/ICHRA

Policy updates include:

· Added new formulation Evdi to policy

Atezolizumab (Tecentriq), Atezolizumab-Hyaluronidase (Tecentriq Hybreza) (CP.PHAR.235)

Ambetter/ICHRA

Policy updates include:

· Added muscle invasive bladder cancer indication per updated package insert

· For PD-L1 positive urothelial carcinoma, removed requirement for ineligibility for cisplatin-containing chemotherapy per National Comprehensive Cancer Network (NCCN)

Eribulin mesylate (Halaven) (CP.PHAR.318)

Ambetter/ICHRA

Policy updates include:

· Added requirement that member must use generic eribulin mesylate for brand Halaven requests.

Durvalumab (Imfinzi) (CP.PHAR.339)

Ambetter/ICHRA

Policy updates include:

· Added criteria for newly Food and Drug Administration (FDA)-approved indication of Bacillus Calmette-Guérin (BCG)-naïve, high-risk non-muscle-invasive bladder cancer

· Added urologist prescriber option for muscle invasive bladder cancer

Fam-trastuzumab deruxtecan-nxki (Enhertu) (CP.PHAR.456)

Ambetter/ICHRA

Policy updates include:

· Added two newly approved indications for use as adjuvant and neoadjuvant therapy in early breast cancer

Added ICHRA line of business

Decitabine-Cedazuridine (Inqovi) (CP.PHAR.479)

Ambetter/ICHRA

Policy updates include:

· Added criteria for newly approved Food and Drug Administration (FDA) indication for acute myeloid leukemia

Efgartigimod alfa, efgartigimod-hyaluronidase (Vyvgart, Vyvgart Hytrulo) (CP.PHAR.555)

Ambetter/ICHRA

Policy updates include:

· Updated generalized myasthenia gravis indication for expansion to all serotypes of generalized myasthenia gravis and added additional serotype criteria options

· Added qualifier of anti- acetylcholine receptor (achr) antibody-positive generalized myasthenia gravis for required failure of a cholinesterase inhibitor

For concurrent therapy exclusions for generalized myasthenia gravis, added Uplizna

Zenocutuzumab-zbco (Bizengri) (CP.PHAR.713)

Ambetter/ICHRA

Policy updates include:

· Added new Food and Drug Administration (FDA) approved indication for cholangiocarcinoma

· Consolidated non-small cell lung cancer, pancreatic adenocarcinoma, and cholangiocarcinoma criteria into one section

Etuvetidigene Autotemcel (Waskyra) (CP.PHAR.735)

Ambetter/ICHRA

Policy updates include:

· Added ICHRA line of business

Semaglutide (Wegovy) (CP.PMN.295)

Ambetter/ICHRA

Policy updates include:

· New formulation Wegovy prefilled syringe to policy

Opioid Analgesics (HIM.PA.139)

Ambetter/ICHRA

Policy updates include:

· For brand Nucynta ER, added requirement that member must use generic tapentadol ER