Effective December 1, 2024: Pharmacy and Biopharmacy Policies

POLICY

APPLICABLE PRODUCTS

NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS

Belimumab (Benlysta) (CP.PHAR.88)

Medicaid

Policy updates include:

·         Updated systemic lupus erythematosus dosing for subcutaneous to reflect expanded indication to patients 5+ years old

Aflibercept (Eylea, Eylea HD, Opuviz, Yesafili, Ahzantive, Enzeevu, Pavblu) (CP.PHAR.184)

Medicaid

Policy updates include:

·         Added new Eylea biosimilars Enzeevu and Pavblu; expanded retinopathy of prematurity indication criteria to also allow use of the biosimilars – Opuviz, Yesafili, Ahzantive, Enzeevu, and Pavblu

Ranibizumab (Byooviz, Cimerli, Lucentis, Susvimo) (CP.PHAR.186)

Medicaid

Policy updates include:

·         In initial approval criteria, separated diabetic macular edema and diabetic retinopathy into a new section and clarified request is for Cimerli or Lucentis

Abatacept (Orencia) (CP.PHAR.241)

Medicaid

Policy updates include:

·         For pJIA, PsA, RA, added Simlandi to listed examples of preferred adalimumab products.

Adalimumab (Humira), Adalimumab-afzb (Abrilada), Adalimumab-atto (Amjevita), Adalimumab-adbm (Cyltezo), Adalimumab-bwwd (Hadlima), Adalimumab-fkjp (Hulio), Adalimumab-adaz (Hyrimoz), Adalimumab-aacf (Idacio), Adalimumab-ryvk (Simlandi), Adalimumab-aaty (Yuflyma), Adalimumab-aqvh (Yusimry) (CP.PHAR.242)

Medicaid

Policy updates include:

·         Added Simlandi new prefilled syringe formulation and strengths [20 mg/0.2 mL, 40 mg/0.4 mL, 80 mg/0.8 mL]

·         Added adalimumab-ryvk [NDC 82009-0156-22] to list of requested products where redirection would apply

·         Added adalimumab-aaty (unbranded Yuflyma) with specific NDCs [72606-0022-09, 72606-0022-10, 72606-0040-04, 72606-0041-01, 72606-0022-06] to Appendix K and to list of preferred adalimumab products

·         For section V, added Simlandi pediatric dose for polyarticular juvenile idiopathic arthritis [15 kg to less than 30 kg: 20 mg every other week] and pediatric dose for CD [17 kg to less than 40 kg: 80 mg subcutaneous on Day 1, 40 mg subcutaneous on Day 15, then 20 mg subcutaneous every other week starting on Day 29]

·         For Appendix K, added preferred Simlandi NDCs [51759-0386-22, 51759-0412-22, 51759-0386-22]

Certolizumab (Cimzia) (CP.PHAR.247)

Medicaid

Policy updates include:

·         Added Simlandi to listed examples of preferred adalimumab products.

Etanercept (Enbrel) (CP.PHAR.250)

Medicaid

Policy updates include:

·         Added Simlandi to listed examples of preferred adalimumab products.

Golimumab (Simponi, Simponi Aria) (CP.PHAR.253)

Medicaid

Policy updates include:

·         Added Simlandi to listed examples of preferred adalimumab products.

Ixekizumab (Taltz) (CP.PHAR.257)

Medicaid

Policy updates include:

·         Added new strengths for single-dose prefilled syringe [20 mg/0.25 mL, 40 mg/0.5 mL]

Natalizumab (Tysabri), Natalizumab-sztn (Tyruko) (CP.PHAR.259)

Medicaid

Policy updates include:

·         For CD, added Simlandi to listed examples of preferred adalimumab products.

Secukinumab (Cosentyx) (CP.PHAR.261)

Medicaid

Policy updates include:

·         For AS, PsO, PsA, HS, added Simlandi to listed examples of preferred adalimumab products.

Tocilizumab (Actemra), Tocilizumab-bavi (Tofidence), Tocilizumab-aazg (Tyenne) (CP.PHAR.263)

Medicaid

Policy updates include:

·         For RA and pJIA, added Simlandi to listed examples of preferred adalimumab products.

·         For COVID-19 and giant cell arteritis, added Tofidence to criteria

·         For section V, added Tofidence dosing for giant cell arteritis

Ustekinumab (Stelara), Ustekinumab-ttwe (Pyzchiva), Ustekinumab-aekn (Selarsdi), Ustekinumab-auub (Wezlana) (CP.PHAR.264)

Medicaid

Policy updates include:

·         Added Simlandi to listed examples of preferred adalimumab products.

Vedolizumab (Entyvio) (CP.PHAR.265)

Medicaid

Policy updates include:

·         Added Simlandi to listed examples of preferred adalimumab products.

Paliperidone inj (Invega Sustenna, Invega Trinza, Invega Hafyera, Erzofri) (CP.PHAR.291)

Medicaid

Policy updates include:

·         Added newly approved Erzofri to the policy

Asfotase Alfa (Strensiq) (CP.PHAR.328)

Medicaid

Policy updates include:

·         generalized initial approval diagnostic laboratory indices criteria language.

Cerliponase alfa (Brineura) (CP.PHAR.338)

Medicaid

Policy updates include:

·         Updated criteria to reflect the newly Food and Drug Administration (FDA)-approved indication expansion to include symptomatic and presymptomatic patients younger than 3 years of age, including the following changes: removed any references to “late infantile” disease, replaced the age requirement with the 2.5 kg minimum weight requirement per dosing recommendations in the Prescribing Information.

·         Added the Boxed Warning re: hypersensitivity reactions including anaphylaxis.

Durvalumab (Imfinzi) (CP.PHAR.339)

Medicaid

Policy updates include:

·         Added criteria for newly Food and Drug Administration (FDA)-approved indication for use as neoadjuvant/adjuvant therapy in resectable non-small cell lung cancer

·         Revised Commercial continued approval duration from 12 months to standard duration for injectables, 6 months or to the member’s renewal date, whichever is longer

Guselkumab (Tremfya) (CP.PHAR.364)

Medicaid

Policy updates include:

·         Added Simlandi to listed examples of preferred adalimumab products.

Brodalumab (Siliq) (CP.PHAR.375)

Medicaid

Policy updates include:

·         Added Simlandi to listed examples of preferred adalimumab products.

Corticosteroids for Ophthalmic Injection (Dextenza, Iluvien, Ozurdex, Retisert, Xipere, Yutiq) (CP.PHAR.385)

Medicaid

Policy updates include:

·         For diabetic macular edema, macular edema, and uveitis, removed required step through of intravitreal steroid injections due to lack of commercial availability (Triesence is the only intravitreal steroid injection on market, and it is currently on shortage without a known resolution date)

Tildrakizumab-asmn (Ilumya) (CP.PHAR.386)

Medicaid

Policy updates include:

·         Added Simlandi to listed examples of preferred adalimumab products.

Human Growth Hormone (Somapacitan, Somatrogon, Somatropin, Lonapegsomatropin-tcgd) (CP.PHAR.517)

Medicaid

Policy updates include:

·         Added Skytrofa to policy.

·         Added redirection to Omnitrope vial to co-prefer Zomacton and Omnitrope vial.

·         Revised Omnitrope vial to Omnitrope pen cartridge if Zomacton and Omnitrope vial are not available (e.g., due to drug shortage).

·         Added redirection to other diagnoses/indications sections for both initial and continuation requests.

Fibrinogen concentrate (human) (Fibryga, RiaSTAP) (CP.PHAR.526)

Medicaid

Policy updates include:

·         Updated Fibryga with new Food and Drug Administration (FDA) indication for acquired fibrinogen deficiency

Insulin Delivery Systems (V-Go, Omnipod, InPen) (CP.PHAR.534)

Medicaid

Policy updates include:

·         For Omnipod 5, updated the Food and Drug Administration (FDA) Approved Indication section to reflect newly approved use of the SmartAdjust technology in adults with type 2 diabetes

Donanemab-azbt (Kisunla) (CP.PHAR.594)

Medicaid

Policy updates include:

·         Drug is now Food and Drug Administration (FDA)-approved – criteria updated per Food and Drug Administration (FDA) labeling for treatment of Alzheimer’s disease.

·         For Continued Therapy updated the required follow-up MRI schedule, treatment discontinuation thresholds, and MRI-contingent reauth durations.

Bimekizumab-bkzx (Bimzelx) (CP.PHAR.660)

Medicaid

Policy updates include:

·         Added Simlandi to listed examples of preferred adalimumab products.

Mirikizumab-mrkz (Omvoh) (CP.PHAR.662)

Medicaid

Policy updates include:

·         Added Simlandi to listed examples of preferred adalimumab products.