Policy

Policy Name

Revision

Effective Date

CP.PHAR.121

Nivolumab, Nivolumab Hyaluronidase-nvhy (Opdivo, Opdivo Qvantig)

HCPCS code added [J9289]; RT4: updated FDA Approved Indication(s) section and criteria to reflect revised indication that limits use to tumors expressing PD-L1 (≥ 1) in combination with chemotherapy for unresectable advanced or metastatic ESCC in first-line setting and gastric cancer, GEJ cancer and esophageal adenocarcinoma (previously approved regardless of PD-L1 status); also for MSI-H or dMMR esophageal cancers, specified usage as perioperative therapy when prescribed as a single age, as induction or palliative therapy when prescribed combination with fluoropyrimidine-containing chemotherapy, and as induction, neoadjuvant, perioperative, or palliative when prescribed in combination with Yervoy; updated Appendix F with revised language and exception for Tennessee.

10/01/25

CP.PHAR.319

Ipilimumab (Yervoy)

RT4: updated FDA Approved Indication(s) section and criteria to reflect revised indication that limits use to tumors expressing PD-L1 (≥ 1) for unresectable advanced or metastatic ESCC in combination with Yervoy per updated PI (previously approved regardless of PD-L1 status); also for ESCC, added option to be prescribed as palliative therapy and clarified when prescribed as induction, neoadjuvant, perioperative, or palliative therapy that tumor is characterized as MSI-H or dMMR.

10/01/25

CP.PHAR.367

Letermovir (Prevymis)

For prophylaxis of CMV in kidney transplant recipients, added criterion limiting usage of Prevymis up to day 200 post-transplantation.

10/01/25

CP.PHAR.605

Adagrasib (Krazati)

Per SDC for CRC, added redirection to Lumakras; for NCSLC and CRC, added step therapy bypass for IL HIM per IL HB 5395.

10/01/25

CP.PMN.192

Brimonidine (Mirvaso)

Added redirection for brand Mirvaso requests to generic topical brimonidine.

10/01/25