Effective July 1, 2025: Pharmacy and Biopharmacy Policies

POLICY

APPLICABLE PRODUCTS

NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS

Leuprolide Acetate (Lupron, Eligard, Lupaneta Pack, Fensolvi, Camcevi)  (CP.PHAR.173)

Medicaid

Policy updates include:

·         For endometriosis and uterine leiomyomata (fibroids), added allowance for age < 18 years when member is postpubertal per prescribing information

Ranibizumab (Lucentis, Susvimo), Lucentis Biosimilars (CP.PHAR.186)

Medicaid

Policy updates include:

·         For Susvimo, updated Food and Drug Administration (FDA) indication to include diabetic macular edema and clarified maximum dose is 2 mg (one 100 mg/mL vial) per 6 months

Buprenorphine (Sublocade, Brixadi) (CP.PHAR.289)

Medicaid

Policy updates include:

·         For Sublocade, updated criteria to include Food and Drug Administration (FDA) approved rapid initiation protocol (previously required 7 days of transmucosal buprenorphine)

Panitumumab (Vectibix) (CP.PHAR.321)

Medicaid

Policy updates include:

·         Added new Food and Drug Administration (FDA)-approved indication of Kirsten rat sarcoma 2 viral oncogene homologue (KRAS) G12C-mutated colorectal cancer

·         Removed prior therapy requirement when prescribed for BRAF V600E mutation positive in combination with Braftovi and added clarification that regimen may be “with or without fluorouracil, leucovorin, oxaliplatin (FOLFOX)” per National Comprehensive Cancer Network (NCCN)

·         Modified requirement for left-sided colon cancer to also apply to unresectable metachronous metastases per National Comprehensive Cancer Network (NCCN)

Denosumab (Prolia, Xgeva), Denosumab-bbdz (Jubbonti, Wyost), Denosumab-dssb (Ospomyv, Xbryk), Denosumab-bmwo (Stoboclo, Osenvelt) (CP.PHAR.58)

Medicaid

Policy updates include:

·         Added new biosimilars denosumab-dssb, Osenvelt, Ospomyv, Stoboclo, and Xbryk to criteria

Avacincaptad pegol (Izervay) (CP.PHAR.641)

Medicaid

Policy updates include:

·         Per updated Food and Drug Administration (FDA) label removal of the one-year duration limit for the treatment of geographic atrophy, removed continued authorization criterion for treatment exceeding 12 months

·         Increased Medicaid/Ambetter continued approval duration from 6 months to 12 months for this chronic condition

Eculizumab (Soliris, Bkemv, Epysqli) (CP.PHAR.97)

Medicaid

Policy updates include:

·         Updated Food and Drug Administration (FDA) approved indication for Soliris to include generalized myasthenia gravis 6 years old pediatric expansion

·         For atypical hemolytic uremic syndrome, generalized myasthenia gravis, and neuromyelitis optica spectrum disorder, updated dose maximum and added asterisk stating additional doses of eculizumab may be approved if the member is receiving plasmapheresis, plasma exchange, fresh frozen plasma, or intravenous immunoglobulin

·         Added Appendix E to provide supplemental dosing information

Brentuximab Vedotin (Adcetris) (CP.PHAR.303)

Medicaid

Policy updates include:

·         Added criteria for new Food and Drug Administration (FDA)-approved indication of relapsed or refractory large B-cell lymphoma in adult patients   – added criterion that disease is relapsed or refractory, added option that member is not a candidate for chimeric antigen receptor (CAR) T-cell therapy

·         Per National Comprehensive Cancer Network (NCCN) for B-cell lymphomas – added pathway for off-label use as a single agent or in combination with rituximab or nivolumab, clarified use in human immunodeficiency virus (HIV)-related B-cell lymphoma and post-transplant lymphoproliferative disorder are off-label indications

Apomorphine (Apokyn, Apokyn NXT, Onapgo) (CP.PHAR.488)

Medicaid

Policy updates include:

·         Added new formulations Apokyn NXT and Onapgo to policy

·         Added generic apomorphine to policy requiring prior authorization

·         For Apokyn or Apokyn NXT, added must use generic apomorphine language

·         Revised “prescribed concurrently with an anti-Parkinson agent” to “prescribed concurrently with levodopa/carbidopa”

·         Added requirement for trial and failure of at least two anti-Parkinson agents from different therapeutic classes, unless clinically significant adverse events are experienced or all are contraindicated