Effective December 1, 2026: Pharmacy and Biopharmacy Policies

Cabozantinib (Cabometyx, Cometriq, Omcazio) (CP.PHAR.111)

Medicaid and CHIP

RT4: added new capsule formulation Omcazio.

Ropeginterferon alfa-2b-njft (Besremi) (CP.PHAR.570)

Medicaid and CHIP

RT4: added new FDA-approved indication of essential thrombocythemia and removed it from NCCN Recommended Uses (off-label) section; for essential thrombocythemia, added requirement for prior cytoreductive therapy per NCCN and pivotal study design as an alternative option to the requirement for use as a substitute for peginterferon alfa-2a.

Tislelizumab-jsgr (Tevimbra) (CP.PHAR.687)

Medicaid and CHIP

RT4: updated criteria to include new indication in combination with zanidatamab-hrii and chemotherapy for first-line HER2+ G/GEJ or esophageal adenocarcinoma per updated PI.

Zanidatamab-hrii (Ziihera) (CP.PHAR.709)

Medicaid and CHIP

RT4: updated criteria to include new indications in combination with fluoropyrimidine- and platinum-containing chemotherapy ± tislelizumab-jsgr for first-line HER2+ gastric, gastroesophageal junction, or esophageal adenocarcinoma per updated PI.

Garetosmab (Pasatru) (CP.PHAR.778)

Medicaid and CHIP

Drug is now FDA approved. Criteria is only applicable for Medicaid and CHIP when the drug is added to the medical benefit for coverage. Requests for indications not approved by the FDA are reviewed with the off-label use policy MS.PMN.53.

Initial Approval Criteria: Fibrodysplasia Ossificans Progressiva (must meet all):

o   Diagnosis of FOP;

o   Prescribed by or in consultation with an orthopedics, orthopedic surgery, rheumatology, endocrinology, medical genetics, or metabolic disease specialist;

o   Age ≥ 18 years;

o   Presence of ACVR1 FOP-causing mutation;

o   Documentation of both of the following baseline tests assessed by low-dose whole body computed tomography (WBCT) scan, excluding the head:

§  HO volume;

§  HO lesion count;

o   Member has a cumulative analog joint involvement scale (CAJIS) score ≤ 19 prior to treatment with Pasatru;

o   Failure of both of the following at up to maximally indicated doses, unless clinically significant adverse effects are experienced or all are contraindicated:

§  Prednisone used for flare-ups;

§  Two nonsteroidal anti-inflammatory drugs (NSAIDs) between flare-ups;

o   Pasatru is not prescribed concurrently with Sohonos^™;

o   Documentation of member’s body weight in kg;

o   Dose does not exceed 10 mg/kg every 4 weeks.

o   Approval Duration: 12 months

Continued Therapy: Fibrodysplasia Ossificans Progressiva

o   Member meets one of the following:

§  Currently receiving medication via Centene benefit or member has previously met initial approval criteria;

§  Member is currently receiving medication and is enrolled in a state and product with continuity of care regulations

o   Member is responding positively to therapy as evidenced by one of the following:

§  Reduction in flare-ups from baseline;

§  Reduction in annualized new HO volume as assessed by low-dose WBCT scan;

§  Reduction in new HO lesions as assessed by low-dose WBCT scan;

§  Increased or stabilized mobility;

o   Pasatru is not prescribed concurrently with Sohonos;

o   If request is for a dose increase, both of the following:

§  Documentation of member’s body weight in kg;

§  New dose does not exceed 10 mg/kg every 4 weeks.

o   Approval Duration: 12 months