POLICY

APPLICABLE PRODUCTS

NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS

Rufinamide (Banzel) (CP.PMN.157)

Ambetter

• Added redirection bypass for members in a State with limitations on step therapy in certain settings along with Appendix D, which includes Nevada with requirements for single drug redirection for Medicaid requests
• Removed generic redirection for continuation of therapy requests.

Maribavir (Livtencity) (CP.PMN.271)

Ambetter

Policy updates include:

• Continuation of care  applied to continued therapy section

Valganciclovir (Valcyte) (CP.PCH.06)

Ambetter

Policy updates include:

• Continuation of care  applied to transplant-related indications in continued therapy sections (Section II.A., II.C., II.E.).

Everolimus (Afinitor, Afinitor Disperz, Zortress) (CP.PHAR.63)

Ambetter

Policy updates include:

• Continuation of care  applied to Zortress in continued therapy section II.A.

Biologic and Non-biologic DMARDs (HIM.PA.SP60)

Ambetter

Policy updates include:

• For Stelara, removed redirection criteria for requests that are above the labeled maximum dose.

Ozanimod (Zeposia) (CP.PHAR.462)

Ambetter

• For ulcerative colitis, removed criteria requiring use of Simponi, Humira, and Amjevita
• For ulcerative colitis, added criteria requiring use of one adalimumab product and stating Yusimry, Hadlima, unbranded adalimumab-fkjp, and unbranded adalimumab-adaz as preferred
• Updated Appendix B with relevant therapeutic alternatives.

GLP-1 receptor agonists (HIM.PA.53)

Ambetter

Policy updates include:

• Added newly approved Mounjaro vial formulations.

Dostarlimab-gxly (Jemperli) (CP.PHAR.540)

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

Policy updates include:

• For endometrial carcinoma, added newly approved indication to include first-line use when prescribed in combination with carboplatin and paclitaxel for stage III-IV or recurrent disease