Policy
| Applicable Products
| New Policy Overview or Updated Policy Revisions
|
Eptinezumab-jjmr (Vyepti) (HIM.PA.SP64)
| Ambetter
| Policy includes:- Requests for indications not approved by the FDA are reviewed with the off-label use policy for the relevant line of business: HIM.PHAR.21 for Ambetter
- Initial approval criteria:
- Migraine Prophylaxis (must meet all):
- Diagnosis of episodic or chronic migraine;
- Provider’s attestation that member experiences ≥ 4 migraine days per month for at least 3 months;
- Age ≥ 18 years;
- Failure of at least 2 of the following oral migraine preventative therapies, each for 8 weeks and from different therapeutic classes, unless contraindicated or clinically significant adverse effects are experienced: antiepileptic drugs (e.g., divalproex sodium, sodium valproate, topiramate), beta-blockers (e.g., metoprolol, propranolol, timolol), antidepressants (e.g., amitriptyline, venlafaxine);
- Failure of Aimovig® and Emgality®, unless contraindicated or clinically significant adverse effects are experienced;
- Vyepti is not prescribed concurrently with Botox® or other injectable CGRP inhibitors (e.g., Aimovig, Ajovy™, Emgality);
- Dose does not exceed 100 mg (1 vial) once every 3 months.
- Approval duration: 3 months
- Continued therapy:
- Migraine Prophylaxis (must meet all):
- Currently receiving medication via Centene benefit or member has previously met initial approval criteria;
- Member has experienced and maintained positive response to therapy as evidenced by provider’s attestation of a reduction in migraine days per month from baseline;
- Vyepti is not prescribed concurrently with Botox or other injectable CGRP inhibitors (e.g., Aimovig, Ajovy, Emgality);
- If request is for a dose increase, new dose does not exceed one of the following (a or b):
- 100 mg (1 vial) once every 3 months;
- 300 mg (3 vials) once every 3 months if medical justification for higher dose is provided.
- Approval duration: 6 months
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Fedratinib (Inrebic) (CP.PHAR.442)
| Ambetter
| Updates include:
- Added redirection to Jakafi
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Fremanezumab-vfrm (Ajovy) (HIM.PA.SP66)
| Ambetter
| Updates include:- Policy created (adapted from CP.PCH.17 which will be retired) to redirect to Aimovig and Emgality
- Removed prescriber requirements
|
Indacterol-glycopyrrolate (Utibron Neohaler) (HIM.PA.102)
| Ambetter
| Updates include:
- Revised redirections to require Anoro Ellipta and Bevespi Aerosphere (removed redirection to either one formulary LABA in combination with LAMA, or one formulary ICS in combination with LABA)
|
Larotrectinib (Vitrakvi) (CP.PHAR.414)
| Ambetter
| Updates include:
- Added redirection to Rozlytrek
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Pegfilgrastim (Neulasta), Pegfilgrastim-jmdb (Fulphila), Pegfilgrastim-cbqv (Udenyca), Pegfilgrastim-bmez (Ziextenzo) (CP.PHAR.296)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Updates include:
- Added new biosimilar Nyvepria to policy
- Added redirection to a biosimilar pegfilgrastim for all indications if member is unable to use Zarxio, including Section II continued therapy
- Added redirection to Ziextenxo for Fulphila, Neulasta, Nyvepria, or Udenyca requests.
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Sodium-Glucose Co-Transporter 2 (SGLT2) inhibitors (HIM.PA.91)
| Ambetter
| Updates include:
- For patients without established CV disease, have risk factors for CV, or diabetic nephropathy modified redirection to require an empagliflozin- and ertugliflozin-containing products
- Added Invokamet XR, Qtern and Qternmet XR to policy
- Added Steglujan and applied revised Glyxambi and Trijardy XR redirection to require an empagliflozin, ertugliflozin, or sitagliptin-containing product.
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