Abrocitinib (Cibinqo) (CP.PHAR.578)

Ambetter

Policy updates include:

• Updated criteria to reflect pediatric extension to age ≥ 12 years

House Dust Mite Allergen Extract (Odactra) (CP.PMN.111)

Ambetter

Policy updates include:

• Updated criteria per FDA approved pediatric extension

Lanadelumab-fylo (Takhzyro) (CP.PHAR.396)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

• Updated FDA approved indication with the pediatric extension and added new lower-volume syringe
• Clarified that Haegarda failure requirement applied to members age ≥ 6 years

Palbociclib (Ibrance) (CP.PHAR.125)

Ambetter

Policy updates include:

• Updated FDA approved indication for breast cancer when used in combination with an aromatase inhibitor to include pre- and peri-menopausal women

Sildenafil (Revatio) (CP.PHAR.197)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

• Updated PAH criteria to include newly FDA approved pediatric age expansion; updated adult PAH dosing per revised PI

Tucatinib (Tukysa) (CP.PHAR.497)

Ambetter

Policy updates include:

• Added criteria for newly FDA-approved indication of colorectal cancer

Zanubrutinib (Brukinsa) (CP.PHAR.467)

Ambetter

Policy updates include:

• Updated policy to reflect now FDA-approved indication of CLL/SLL, which was previously included in policy as off-label
• Added maximum dose option if co-administered with a moderate CYP3A4 inducer
• Clarified that if disease is positive for BTK C481S mutation, member has not had previous disease progression on Imbruvica for indications of MCL and CLL/SLL