Pharmacy Policies Available Online

Avlayah

Ad Hoc review to add embedded step therapy based on MedDrive strategy. Administrative change to update HCPCS for Avlayah. J1757 will be effective on 10/01/2026. J3590 will be discontinued on 10/01/2026. To Appendix 2, updated contractor name from National Government Services, Inc. to Wellpoint Federal. Editorial changes made throughout. 

Bendamustine

Administrative changes to Length of Authorization section to include number of days allowed for authorization durations. To NHL: B-Cell Lymphomas, HIV-Related plasmablastic lymphoma- removed restriction for use in only non-candidates for transplant from subsequent therapy and CAR T bridging therapy. T-Cell Lymphomas – Peripheral T-Cell Lymphomas subsequent therapy, added use in progressive disease per NCCN update. To CLL/SLL first-line therapy in combination with rituximab or obinutuzumab, added criteria that covalent BTK inhibitor and B-cell Lymphoma-2 inhibitor are not available or feasible per NCCN. To Waldenström Macroglobulinemia/Lymphoplasmacytic Lymphoma, for use as alternative therapy, added criteria that member was previously treated with or has CI to BTK inhibitor therapy. Additionally, added use for WM-Related Systemic Light Chain Amyloidosis and criteria per NCCN updates. To Pediatric Hodgkin Lymphoma, updated footnote for those who may avoid ASCR per NCCN update. To Billing Code Information, HCPCS code description updated for J9033. To NDCs, updated notations for generic availability for Treanda, Bendeka, and Belrapzo. Additionally, administrative change was made to add the new bendamustine hydrochloride Avyxa product approved via the 505(b)(2) pathway along with HCPCS code J9066 which will be effective on 10/01/2026. This new product will be kept at full parity with the reference product, Treanda. Added NDC for Vivimusta. 505(b)(2) footnote language was also updated and now includes a link to the FDA NDC Directory. To Appendix 1, added ICD-10 code C83.36 (related to DLBCL) per NCCN. To Appendix 2, updated contractor name from National Government Services, Inc. to Wellpoint Federal. Editorial changes made throughout.

Beovu

Administrative change to Length of Authorization section to include number of days allowed for authorization durations. To Universal Criteria, global change to remove any specific contraindications in criteria and replaced with general language indicating member does not have any FDA contraindications. Coding updates were made to CMS reference A52451 (jurisdiction 6, K). To availability section, made notation that vial formulation is no longer commercially available, per Rx Claims review. To Appendix 2, updated contractor name from National Government Services, Inc. to Wellpoint Federal. Editorial changes made throughout.

Bevacizumab Oncology

To Dosing Limits section, added HCPCS codes and separated out unclassified code J9999 to list its max units in milligrams. To CRC, simplified criteria by removing duplicative option for use as primary treatment of T3, N Any; T1-2, N1-2; T4, N Any; or locally unresectable or medically inoperable rectal cancer. To NSCLC, updated options for use in recurrent, advanced or metastatic disease to align with NCCN guideline recommendations. To Appendix 2 - CMS, updated contractor information for LCA A52370 from National Government Services, Inc. to Wellpoint Federal. Editorial changes throughout.

Cyramza

Administrative changes to Length of Authorization section to include number of days allowed for authorization durations. Removed indication of Appendiceal Adenocarcinoma from all affected sections, as this is no longer recommended in NCCN compendia and is not an FDA approved use. To CRC, for use as subsequent treatment, added requirement that member has been previously treated with oxaliplatin-based regimen per the PI and NCCN. To HCC, removed the criteria requiring Child Pugh Class based on NCCN updates. To NSCLC, made updates to L858R mutation naming convention to match latest guidelines. To Thymic Carcinoma section, added definition of R0 resection, for clarity. Streamlined dosing regimens in dosing table to combine similar dosing patterns together to match Dosing Limits section. To Appendix 1, removed ICD-10 code C18.1 related to Appendiceal Neoplasms & Cancers. To Appendix 2, updated contractor name from National Government Services, Inc. to Wellpoint Federal.

Denosumab

Ad hoc review to add the Prolia biosimilars, Ponlimsi and denosumab-adet, in anticipation of launch into the marketplace and to add new classified HCPCS code effective 10.01.2026, Q5173. J3590 will be discontinued for Ponlimsi and denosumab-adet on 10.01.2026. To initial criteria updated indication naming for use in Breast and Prostate cancer to more closely align with PI. To renewal criteria for Osteoporosis in Men and Women and Glucocorticoid OP added clarifying statement to confirm member’s fracture risk has been reassessed. Removed HCPCS J3590 for Enoby/Xtrenbo, Osvyrti/Jubereq, Boncresa, and Oziltus as it was discontinued on 07.01.2026. Administrative change to Appendix 2 to remove list of covered products and, update contractor name from National Government Services, Inc. to Wellpoint Federal. Coding updates made to CMS reference A52399 (jurisdiction 6, K). Editorial changes made throughout.

Elahere

Administrative changes to Length of Authorization section to include the number of days allowed. To Appendix 2, updated contractor name from National Government Services, Inc. to Wellpoint Federal for jurisdictions 6 and K (13 & 14). Editorial changes made throughout.

Encelto

To Universal Criteria, consolidated bullets pertaining to contraindications to a singular bullet stating the member does not have any FDA labeled contraindication to the requested agent. To Appendix 2, updated contractor name from National Government Services, Inc. to Wellpoint Federal for jurisdictions 6 and K (13 & 14). Editorial changes made throughout.

Halaven

Administrative change to Length of Authorization section to include number of days allowed for authorization durations. To Breast Cancer, under TNBC first line therapy, update made to include members who are not a candidate for PD-1/PD-L1 inhibitor therapy, based on NCCN guideline update. Also, added indication of Borderline/Malignant Phyllodes Tumor of the Breast and made appropriate update to ICD 10 table (added codes D48.60, D48.61, and D48.62). To Appendix 1, added ICD-10 codes C50.A0-C50.A2 (related to inflammatory breast cancer). To Appendix 2, updated contractor name from National Government Services, Inc. to Wellpoint Federal. Editorial changes made throughout. 

Infliximab

Ad hoc review to update the Max Units in the Dosing Limits section to align with the PI max dosing. To Appendix 2 and the References section, updated the contractor name from National Government Services, Inc. to Wellpoint Federal.

Ixempra

Administrative changes to Length of Authorization section to include number of days allowed for authorization durations. Global change was made to remove specific contraindications in criteria and replace with general language indicating member does not have any FDA labeled contraindications. To Breast Cancer, updated verbiage throughout to align with NCCN and added option for first line therapy for TNBC for members who are not candidates for PD-1/PD-L1 therapy. Updated HER2-negative and HER2-positive expression criteria tables to align with NCCN verbiage. To Appendix 1 - Covered Diagnosis Codes, added C50.A0, C50.A1, and C50.A2 (related to Breast Cancer) per NCCN. To Appendix 2, updated contractor name from National Government Services, Inc. to Wellpoint Federal for jurisdictions 6 and K (13 & 14). Editorial changes made throughout.

Kyxata

To Billing Code/Availability, removed discontinued HCPCS codes C9308 and J9999. To Appendix 2, updated contractor name from National Government Services, Inc. to Wellpoint Federal for jurisdictions 6 and K (13 & 14). Editorial changes made throughout.

Omalizumab

Ad hoc review to align with the updates made to the Prime Therapeutics Xolair_omalizumab_PA policy: added the FDA approved biosimilar Omlyclo product with criteria and self-administration embedded steerage aligned with the self-administered Xolair products. Renamed the policy to Omalizumab to reflect inclusion of both products. Updated the Billing/Availability section to add the Omlyclo HCPCS coding details and available prefilled syringe dosage formulations: 75 mg, 150 mg, and 300 mg. Coding updates were made to CMS reference A52448 (jurisdiction 6,K). To Appendix 2, updated contractor name from National Government Services, Inc. to Wellpoint Federal.

Paclitaxel Albumin-Bound

To Breast cancer, added additional use criteria for TNBC for single agent or use with carboplatin as first line therapy in members with no germline BRCA 1/2 pathogenic variant if they are not a candidate for PD-1/PD-L1 inhibitors. To NSCLC, added back 2B exclusion for use in locoregional recurrence or symptomatic local disease without evidence of disseminated disease. To Appendix 2 and references, updated contractor name from National Government Services, Inc. to Wellpoint Federal.

Pemetrexed

To NS-NSCLC, updated criteria to align with NCCN compendia and guideline recommendations. To Billing Code/Availability Information, added an additional Pemfexy NDC per IPD Analytics and FDA NDC Directory. To Appendix 2, updated contractor name from National Government Services, Inc. to Wellpoint Federal. Editorial changes made throughout.

Pluvicto

Administrative changes to Length of Authorization section to include number of days allowed for authorization durations. To initial approval criteria, added use of a FDA-approved PSMA positron emission tomography (PET) product to identify for prostate-specific membrane antigen (PSMA) expression in tumors due to specification of testing in NCCN guideline. To Prostate cancer added new FDA approved indication for metastatic androgen pathway modulation-naïve or -sensitive prostate cancer (mAPMN/S) and corresponding criteria. To dose/admin table updated indication naming to encompass all indications and removed note regarding safety/handling of the medication for conciseness. To billing/coding updated NDC based on new FDA PI. To Appendix 2, updated contractor name from National Government Services, Inc. to Wellpoint Federal. Editorial changes made throughout.

Ranibizumab

To Billing Code/Availability section added one new NDC for Byooviz for the 0.5 mg/0.05 mL single-use vial for injection formulation and inserted NDC numbers for the products that were previously undesignated within the policy for Nufymco per IPD/latest FDA package inserts. Coding updates were made to CMS reference A52451 (jurisdiction 6, K). To Appendix 2, updated contractor name from National Government Services, Inc. to Wellpoint Federal. Editorial changes made throughout.

Rytelo

Administrative change to Length of Authorization section to include number of days allowed for authorization durations. To MDS, removed criteria for members with a del(5q) mutation as this is no longer supported by NCCN. To Appendix 2, updated contractor name from National Government Services, Inc. to Wellpoint Federal. Editorial changes made throughout.

Sarclisa IV

Ad hoc review to update use with pomalidomide and dexamethasone for multiple myeloma after 2 prior lines of therapy to now instead allow use after prior therapy with lenalidomide and PI based on the IRAKLIA trial which had similar ORR for the SQ and IV formulations in this setting. To Appendix 2, updated contractor name from National Government Services, Inc. to Wellpoint Federal.

Susvimo

Administrative change to Length of Authorization section to include number of days allowed for authorization durations. To Universal Criteria, global change to remove any specific contraindications in criteria and replaced with general language indicating member does not have any FDA contraindications. Added CMS reference A52451 (jurisdiction 6, K). Updated E08.319 code description. Editorial changes made throughout.

Syfovre

Administrative change to Length of Authorization section to include number of days allowed for authorization durations. Global change to remove specific contraindications in Universal Criteria and replace with general language indicating member does not have any FDA labeled contraindications. To Appendix 2, updated contractor name from National Government Services, Inc. to Wellpoint Federal. Editorial changes throughout.

Trastuzumab IV

To Breast Cancer, added new NCCN 2A rec for use as preoperative therapy in adults with high risk of recurrence or with a primary tumor stage T3-4 early invasive or inflammatory disease. Dosing Table and LOA sections were updated accordingly. To CRC, added ‘advanced’ to rec on unresectable/metastatic disease for primary treatment in order to simplify criteria by removing the rectal only criteria and aligning with NCCN. Also removed CRC from Dosing Table row with H&N Cancers as current dosing aligns better with ‘all other indications’. To Dosing Table, added combination therapy and single agent therapy headings to H&N for clarity. To Appendix 2, updated contractor name from National Government Services, Inc. to Wellpoint Federal. Updated ICD-10 PCM Crosswalk. Editorial changes made throughout.

Vabysmo

To Universal Criteria, global change to remove any specific contraindications in criteria and replaced with general language indicating member does not have any FDA contraindications. Coding updates were made to CMS reference A52451 (jurisdiction 6, K). To Appendix 2, updated contractor name from National Government Services, Inc. to Wellpoint Federal. Editorial changes made throughout.

Vyloy

Administrative change to Length of Authorization section to include number of days allowed for authorization durations. To Appendix 2, updated contractor name from National Government Services, Inc. to Wellpoint Federal. Editorial changes throughout.

Xolair

XOLAIR policy will be renamed OMALIZUMAB (to account for Omlyclo addition)

Zaltrap

Administrative change to Length of Authorization section to include number of days allowed for authorization durations. To Colorectal Cancer, updated criteria to encompass PI and NCCN recommendations. Removed Appendiceal Adenocarcinoma indication from all affected sections as this is no longer supported by NCCN. To Appendix 1, removed ICD-10 code C18.1 related to Appendiceal Neoplasms and Cancers. To Appendix 2, updated contractor name from National Government Services, Inc. to Wellpoint Federal. Editorial changes made throughout.

Zepzelca

Administrative changes to Length of Authorization section to include number of days allowed for authorization durations. To SCLC, added footnote stating systemic cytotoxic chemotherapy is recommended for transformed SLCL from NSCLC with an oncogenic driver. To Appendix 2, updated contractor name from National Government Services, Inc. to Wellpoint Federal. Editorial changes made throughout.