Policy
| Applicable Products
| New Policy Overview or Updated Policy Revisions
|
Ferumoxytol (Feraheme) (CP.PHAR.165)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Modified to redirect from brand Venofer to generic
|
Ferric Carboxymaltose (Injectafer) (CP.PHAR.234)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Modified to redirect from brand Venofer to generic
|
Ferric Derisomaltose (Monoferric) (CP.PHAR.480)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Modified to redirect from brand Venofer to generic
|
Concizumab-mtci (Alhemo) (CP.PHAR.625)
| Ambetter
| Policy updates include:
- Added new indication for hemophilia A and B without inhibitors
- Added continued therapy criterion for provider confirmation that member has discontinued any use of Hemlibra, bypassing agents, FVIII, or FIX products as prophylactic therapy while on Alhemo
|
Romiplostim (Nplate) (CP.PHAR.179)
| Ambetter, Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), and CHIP
| Policy updates include:
- Added redirection to eltrombopag (generic Promacta) for immune thrombocytopenia and myelodysplastic syndromes
- For immune thrombocytopenia removed redirection to immune globulin if intolerant or contraindicated to systemic corticosteroid
- For immune thrombocytopenia and National Comprehensive Cancer Network (NCCN) supported uses, revised initial approval duration from 6 to 12 months
|
Eltrombopag (Alvaiz, Promacta) (CP.PHAR.180)
| Ambetter
| Policy updates include:
- Added redirection to eltrombopag (generic Promacta)
- For immune thrombocytopenia removed redirection to immune globulin if intolerant or contraindicated to systemic corticosteroid
- For all indications other than hepatitis C-associated thrombocytopenia, revised initial approval duration from 6 to 12 months.*For Health Insurance Marketplace (HIM), if request is through pharmacy benefit, Alvaiz is non-formulary and should not be approved using these criteria
- Refer to the formulary exception policy, HIM.PA.103
|
Fostamatinib (Tavalisse) (CP.PHAR.24)
| Ambetter
| Policy updates include:
- Added redirection to eltrombopag (generic Promacta)
- Removed redirection to immune globulin if intolerant or contraindicated to systemic corticosteroid
- Revised initial approval duration from 6 to 12 months
|
Valbenazine (ingrezza, Ingrezza Sprinkle) (CP.PHAR.340)
| Ambetter
| Policy updates include:
- Added Health Insurance Marketplace (HIM) line of business (removed from CP.PCH.48 which is being retired)
|
Donidalorsen (Dawnzera) (CP.PHAR.717)
| Ambetter, Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), and CHIP
| Policy updates include:
- Added redirection to one of the following: Haegarda, Takhzyro, or Orladeyo
|
Tiopronin Delayed-Release (Thiola EC) (CP.PHAR.725)
| Ambetter
| Policy updates include:
- Added requirement for Thiola EC requests that member must use tiopronin delayed-release (generic Thiola EC)
|
Immune Globulins (CP.PHAR.103)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), and CHIP
| Policy updates include:
- Removed Health Insurance Marketplace (HIM) line of business
- For continued therapy, added language “(or health plan-preferred* immune globulin product)” to continue its usage, unless medical justification supports necessity for immune globulin product switch
|
Perampanel (Fycompa) (CP.PMN.156)
| Ambetter
| Policy updates include:
- Revised policy/criteria to also include generic parampanel and added required use of generic perampanel for brand Fycompa requests
|
Pregabalin (Lyrica, Lyrica CR) (CP.PMN.33)
| Ambetter
| Policy updates include:
- Added clarification for Commercial and Health Insurance Marketplace (HIM), requests for immediate-release pregabalin (Lyrica) should be reviewed using HIM.PA.109 for Health Insurance Marketplace
|
Insulin glargine (Basaglar, Lantus, Rezvoglar, Toujeo) (HIM.PA.09)
| Ambetter
| Policy updates include:
- Removed redirection to branded Semglee and unbranded Tresiba from policy
- Added redirection to insulin glargine-yfgn (unbranded Semglee) and branded Tresiba
|
Step Therapy Criteria (HIM.PA.109)
| Ambetter
| Policy updates include:
- For Aptiom added redirection to eslicarbazepine (generic Aptiom)
- Added pregabalin immediate-release (Lyrica) requiring step through gabapentin and one of the following: antidepressant, anticonvulsant, buspirone, or cyclobenzaprine
- Removed Azelex from policy
|
Inhaled asthma and COPD agents (HIM.PA.153)
| Ambetter
| Policy updates include:
- For long acting beta-2 agonist / long acting muscarinic antagonist and Ohtuvayre requests revised redirection from brand Anoro Ellipta to umeclidinium/vilanterol (Anoro Ellipta authorized generic), added brand Anoro Ellipta to criteria requiring prior authorization as agent is non-formulary and applied redirection to authorized generic
|
Insulin detemir (Levemir) (HIM.PA.171)
| Ambetter
| Policy updates include:
- Removed redirection to branded Semglee and unbranded Tresiba from policy
- Added redirection to insulin glargine-yfgn (unbranded Semglee) and branded Tresiba
|
Mepolizumab (Nucala) (HIM.PA.175)
| Ambetter
| Policy updates include:
- The following revisions we made: for asthma increased required exacerbations from 1 to 2 in the last 12 months, added redirection to Dupixent and Fasenra
- For eosinophilic granulomatosis with polyangiitis added redirection to Fasenra
- For hypereosinophilic syndrome added redirection to corticosteroid and removed criteria requiring member has tried at least one other hypereosinophilic syndrome treatment for a minimum of 4 weeks
- For chronic rhinosinusitis with nasal polyps increased required intranasal corticosteroids from 1 to 2, added redirection to Dupixent for initial and continuation requests
- For chronic obstructive pulmonary disease added redirection to Dupixent
- Revised initial approval durations from 6 to 12 months
|
Age Limit Override (HIM.PA.177)
| Ambetter
| Policy includes:
- Requests for indications not approved by the FDA are reviewed with the off-label use policy for the relevant line of business: HIM.PHAR.154 for Ambetter
- All requests for non-formulary drugs should be reviewed against HIM.PA.103 Brand Name Override and Non-Formulary Medications
- Initial Approval Criteria: Age Limit Override (must meet all):
- Request is for a formulary drug; *All requests for non-formulary drugs should be reviewed against HIM.PA.103 Brand Name Override and Non-Formulary Medications
- Request is for a drug other than aspirin; *Aspirin is approvable only for members 45 to 79 years of age
- Member’s age exceeds the health plan-approved age limit;
- One of the following:
- Prescribed indication is FDA-approved;
- Prescribed indication is off-label and use is supported by one of the following:
- The National Comprehensive Cancer Network (NCCN) Drug Information and Biologics Compendium level of evidence 1, 2A, or 2B;
- Evidence from at least two high-quality, published studies in reputable peer-reviewed journals or evidence-based clinical practice guidelines that provide all of the following:
- Adequate representation of the member’s clinical characteristics, age, and diagnosis;
- Adequate representation of the prescribed drug regimen;
- Clinically meaningful outcomes as a result of the drug therapy in question;
- Appropriate experimental design and method to address research questions;
- Micromedex DrugDex® with strength of recommendation Class I or IIa;
- For state(s) with state-specific regulations for supportive evidence for requests in pediatrics where member’s age is beyond the FDA labeled indication and prescribing information;
- Request is not for a benefit-excluded use (e.g., cosmetic);
- Requested dose does not exceed health plan-approved quantity limit; *Requess exceeding the health plan-approved quantity limit should also be reviewed against CP.PMN.59 Quantity Limit Override and Dose Optimization
- Dose does not exceed the FDA-approved maximum recommended dose for the relevant indication;
- Approval duration: 12 months
- Continued Therapy: Age Limit Override (must meet all):
- 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;
- Member is responding positively to therapy;
- Requested dose does not exceed health plan-approved quantity limit;
- If request is for a dose increase, new dose does not exceed the Food and Drug Administration (FDA)-approved maximum recommended dose for the relevant indication;
- Approval duration: 12 months
|
SGLT2 inhibitors (HIM.PA.91)
| Ambetter
| Policy updates include:
- Removed reference to branded Farxiga where redirection is stated for dapagliflozin
|
Immune Globulins (HIM.PA.178)
| Ambetter
| Policy updates include:
- Policy created (adapted from CP.PHAR.103) to remove step through Gammagard, Gammaked and Gamunex for Hyqqvia
|
