Pharmacy Policy Updates

UM Program Name

Program Type

Formulary

Update

ACA Copay Waiver

other

Commercial, HIM, NetResults

*Added Yeztugo (lenacapavir) to HIV PrEP criteria as an allowable agent for ACA waiver copay requirements

Agamree Emflaza

PAQL

Commercial, HIM, NetResults

*Updated initial approval length for Agamree to 12 months

Alhemo

PA

Commercial, HIM, NetResults

*Criteria pathways added for indications of hemophilia A without inhibitors and hemophilia B without inhibitors
*For diagnosis of hemophilia A without inhibitors, added Dual Step through Hemlibra and an antihemophilic factor VIII agent
*For diagnosis of hemophilia B without inhibitors, added Single Step through an antihemophilic factor IX agent
*Updated initial approval duration to 12 months
*Added disallowance for use in combination with immune tolerance induction

Alinia

QL

NetResults

Approval duration increased to six months

Alternative Dosage Form

PAQL

NetResults

*Removal of Khindivi as target agent in program

Amifampridine

PAQL

Commercial, HIM, NetResults

Approval duration increased to 12 months

Androgens and Anabolic Steroids

PA/QL

PA: NetResults
QL: Commercial, HIM, NetResults

*Removed Androderm as a Target Agent in the program

Anti-COVID 19

QL

Commercial, HIM, NetResults

Approval duration increased to six months

Antidepressant

STQL

Commercial, HIM, NetResults

*Add missing OR

Antifungals

PAQL

Commercial, HIM, NetResults

*Updated approval length to six months across all modules
*Cresemba and Vfend modules: added criteria requirement that if using for an FDA-approved indication, patient's age must be within FDA labeling or there is support for use in patient's age
*Noxafil, Vfend modules: updated criteria for use in prophylaxis against aspergillosis to require that patient be severely immunocompromised, be a lung transplant recipient or have a history of invasive aspergillosis
*Noxafil module: updated prophylaxis against Candida infection to require patient be severely immunocompromised
*Noxafil, Vfend modules: removed specific renewal requirements for a diagnosis of prophylaxis against invasive aspergillus, now only requires "support for continued use"
*Vfend module: removed criteria pathway for use in prophylaxis against Candida infection

Anti-Influenza

QL

NetResults

Approval duration increased to six months

Atopic Dermatitis

ST

Commercial, HIM, NetResults

*Standardized language and format

Atypical Antipsychotic

STQL

Commercial, HIM, NetResults

Approval duration increased to 12 months

Biologic Immunomodulators (OP2)

PAQL

Commercial, HIM, NetResults

*Removed target NDC 00074433907 (Humira 40 mg/0.8mL PS/UV Starter Kit) as this agent is now obsolete
*Updated Bimzelx 320 mg/2mL quantity limit to one pen/syringe per 56 days (previously one pen/syringe per 28 days)
*Updated criteria to allow bypass of conventional agent requirements if patient has previously used the requested agent
*Removed anthralin as an allowable/required prerequisite for psoriasis
*Additional pathway was added to bypass conventional agent requirements if the patient has severely active Crohn's disease
*Updated approval length to 12 months for all agents/indications
*Added additional pathway to not require that the patient has (or will) receive an IV product for induction therapy if the patient is already established on subcutaneous therapy with the active drug for the requested indication and IV induction therapy is no longer clinically appropriate.
*Simponi requests for ulcerative colitis: Removed note requiring trial and failure of an adalimumab product prior to use
*Added requirement that 200 mg dose of Tremfya should only be used as maintenance therapy for the treatment of ulcerative colitis or Crohn's disease
*Added Starjemza to list of biologic agents that should not be used in combination with other biologic immunomodulators

Bonjesta/Diclegis

PAQL

NetResults

Increase approval length to six months if patient due date cannot be determined

Buprenorphine and Buprenorphine Naloxone

QL

Program retiring

Carbaglu

PA

Commercial, HIM, NetResults

*Updated approval length to 12 months

CFTR

PAQL

Commercial, HIM, NetResults

Approval duration increased to 12 months

CGM

PAQL

Commercial, HIM, NetResults

*Updated quantity limit for Freestyle Libre 2 Plus and Freestyle Libre 3 Plus to 2 sensors per 30 days

CGRP

PAQL

Commercial, HIM, NetResults

*Continuation of Therapy (COT) pathway for migraine prophylaxis updated to allow members already on therapy to bypass additional PA requirements (e.g., age, diagnostics) and updated to verify the requested drug (and strength) is FDA labeled for migraine prophylaxis
*Addition of weight and age check for Ajovy per new indication and labeling under episodic migraine criteria in initial and renewal criteria (pediatric members only)
*Removed criteria requiring that the member not have medication overuse headaches
*For acute migraine treatment, added triptan combination agents as allowable agents that can meet step therapy requirement
*Updated initial approval duration to 12 months for all indications

Coagulation Factor VII

PAQL

Commercial, HIM, NetResults

Approval duration increased to 12 months

Combination Pain Medications

QL

Commercial, HIM, NetResults

Approval duration increased to six months

Constipation Agents

PAQL

NetResults

*Added lubiprostone (generic) as a preferred agent
*Added criteria pathway for members with "another FDA labeled indication" to allow for any future FDA indications
*Removed criteria pathway for Linzess for active cancer pain as NCCN no longer supports this use
*Within renewal criteria for non-preferred agents (Amitiza, Linzess, Motegrity, Ibsrela, Relistor, Movantik) added requirement that patient have failed a preferred agent or be unable to use preferred agents (preferred agents dependent on indication)

Corticotropin

PA

Commercial, HIM, NetResults

*Removal of Acthar gel pen-injector as PA target agent.

Coverage Exception HIM

other

HIM

*Added requirement that if requesting a nonformulary biosimilar agent, patient must have tried for at least three months, and failed three formulary (or as many as available if fewer than three) biosimilar agents or there is support that all available formulary biosimilar agents are contraindicated, likely to be less effective, or cause an adverse reaction or other harm that is not expected to occur with the requested agent
*if patient is currently using the requested agent and is at risk with change, added requirement that use cannot be with samples

Coverage Exception NR

other

NetResults

*Added requirement that if requesting a nonformulary biosimilar agent, patient must have tried for at least three months, and failed three formulary (or as many as available if fewer than three) biosimilar agents or there is support that all available formulary biosimilar agents are contraindicated, likely to be less effective, or cause an adverse reaction or other harm that is not expected to occur with the requested agent
*if patient is currently using the requested agent and is at risk with change, added requirement that use cannot be with samples

Crenessity

PAQL

Commercial, HIM, NetResults

*Removed "due to 21-hydroxylase deficiency" from the diagnosis requirement

Daybue

PAQL

NetResults

Approval duration increased to 12 months

Dojolvi

PA

NetResults

*Updated diagnosis criteria to require two of the following: Disease-specific elevations of acylcarnitines on a newborn blood spot or in plasma, enzyme activity assay (in cultured fibroblasts or lymphocytes) demonstrating deficiency of an enzyme associated with LCFAODs, or genetic testing demonstrating pathogenic mutation in a gene associated with LCFAODs

Dry Eye Disease

PAQL

NetResults

Approval duration increased to six months

Elagolix Relugolix

PAQL

Commercial, HIM, NetResults

*Update to criteria to disallow use of target agents in combination with other elagolix or relugolix agents
*Updated approval lengths to 12 months

Elmiron

PAQL

NetResults

Approval duration increased to 12 months

Empaveli

PAQL

Commercial, HIM, NetResults

*New criteria added for expanded indications - Treatment of adult and pediatric patients aged 12 years and older with C3 glomerulopathy (C3G) AND primary immune-complex membranoproliferative glomerulonephritis (IC-MPGN), to reduce proteinuria
*For diagnosis of PNH, disallowed combination use with Fabhalta, Soliris, Bkemv, Epysqli, Ultomiris or Piasky
*Added nephrologist as an example of a specialist in prescriber specialist requirement
*In quantity limit criteria, added diagnosis check

* Updated approval lengths to 12 months

Enspryng

PAQL

Commercial, HIM, NetResults

*Update to criteria to disallow use of target agents in combination with Rituximab, Soliris, Bkemv, Epysqli, Uplizna, or Ultomiris

Fabhalta

PAQL

Commercial, HIM, NetResults

Approval duration increased to 12 months

Factor VIII and VWF

PAQL

Commercial, HIM, NetResults

Approval duration increased to 12 months

Filsuvez

PA

NetResults

*Added criteria requirement that patient's age be within FDA labeling or there is support for use in patient's age (for patients new to therapy)
*Updated initial approval to 12 months

Gabapentin ER

STQL

ST: Commercial, HIM
QL: Commercial, HIM, NetResults

Quantity limit program added to Commercial and HIM lines of business.

Galafold

PAQL

Commercial, HIM, NetResults

Approval duration increased to 12 months

Gattex

PA

NetResults

Approval duration increased to 12 months

GLP-1

PAQL

Commercial, HIM, NetResults

*Added in MASH diagnosis as bypass to required prerequisite agent therapy with metformin, insulin or combination agent containing metformin or insulin

Gonadotropin Hormones

PAQL

NetResults

Approval duration increased to six months

Growth Hormone

PA

Commercial, HIM, NetResults

*Updated approval length to 12 months for all indications

Hemlibra

PAQL

Commercial, HIM, NetResults

Approval duration increased to 12 months

Hemophilia Factor IX

PAQL

Commercial, HIM, NetResults

Approval duration increased to 12 months

Hepatitis C Direct Acting Antivirals

PAQL

Commercial, HIM, NetResults

*Removed requirement that the requested agent be prescribed by, or in consultation with, a specialist from all modules
*Approval duration increased to six months in all modules
*Added criteria for approving Mavyret in the treatment of acute hepatitis C, new labeled indication

Hereditary Angioedema

PAQL

Commercial, HIM, NetResults

Approval duration increased to 12 months

HSDD

PAQL

NetResults

Approval duration increased to 12 months

Hyftor

PAQL

NetResults

*To criteria requiring three or more facial angiofibromas, added requirement that angiofibromas be "at least 2mm in diameter with redness in each"
*Initial approval increased to 6 months

Hympavzi

PAQL

Commercial, HIM, NetResults

Approval duration increased to 12 months

IL-13 Receptor Antagonists

PAQL

Commercial, HIM, NetResults

Approval duration increased to 12 months

IL-31 Inhibitors

PAQL

Commercial, HIM, NetResults

Approval duration increased to 12 months

IL-5 Inhibitors

PAQL

Commercial, HIM, NetResults

*Added COPD disease specific requirements to support the new FDA labeled indication for Nucala.
*Updated initial approval to 12 months

Imcivree

PAQL

Commercial, HIM, NetResults

Approval duration increased to 12 months

Interleukin (IL)-4 Inhibitors

PAQL

Commercial, HIM, NetResults

*Atopic dermatitis and prurigo nodularis criteria updated to bypass conventional agent requirements if patient has previous use of a biologic approved for the same indication
*Added Bullous Pemphigoid disease specific requirements (new indication)
*Removed post-bronchodilator FEV1 and chronic bronchitis for three months requirements for COPD diagnosis
*For COPD diagnosis, added bypass of criteria requiring exacerbations within the past 12 months if the patient was treated with a biologic immunomodulator for COPD within the past 12 months
*For diagnosis of bullous pemphigoid, added requirement for concomitant therapy with a tapering course of an oral corticosteroid
*Increased initial approval to 12 months

Isturisa

PAQL

Commercial, HIM, NetResults

*Removed requirement that patient's Cushing's syndrome diagnosis was confirmed as persistent or recurrent.
*Updated requirement that the patient not be using the requested agent in combination with glucocorticoid replacement therapy, to clarify concomitant therapy is only disallowed when used for the same indication
*Updated initial approval length to 12 months

Isturisa

PAQL

Commercial, HIM, NetResults

Approval duration increased to 12 months

Joenja

PAQL

NetResults

Approval duration increased to 12 months

Korlym

PAQL

Commercial, HIM, NetResults

*Added criteria pathway for members with "another FDA labeled indication" to allow for any potential new FDA indications
*Updated initial approval to 12 months

Long Acting Insulin

PAQL

Commercial, HIM, NetResults

Quantity limit program added to Commercial and HIM lines of business.

Lyrica and Savella

STQL

ST: Commercial, HIM
QL: Commercial, HIM, NetResults

Quantity limit program added to Commercial and HIM lines of business.

Multiple Sclerosis

PAQL

Commercial, HIM, NetResults

Approval duration increased to 12 months

Myalept

PA

Commercial, HIM, NetResults

*Added continuation of therapy pathway for patients currently using Myalept
*Added requirement that patient have leptin deficiency confirmed by laboratory testing (i.e., less than 12 ng/mL)
*Added criteria pathway for members with "another FDA labeled indication" to allow for any future FDA indications
*Added requirement that patient does not have any limitations for use (as defined in package insert)
*Updated renewal criteria to require generalized "benefit" replacing more specific benefit requirements

Neurotrophic Keratitis

PAQL

Commercial, HIM, NetResults

Approval duration increased to 6 months

Niemann-Pick Type C Agents

PAQL

Commercial, HIM, NetResults

*Added "loss of motor function, difficulty swallowing, speech impairment, cognitive impairment" as examples of required neurological symptoms for approval
*Added disallowance of concurrent use with other targeted agent (Aqneursa or Mipplyfa)
*Initial approval for Aqneursa updated to 12 months

Northera

PAQL

Commercial, HIM, NetResults

Approval duration increased to 12 months

Ophthalmic Prostaglandins

QL

Commercial, HIM, NetResults

ST program being retired, QL still active

Opioid ER

PAQL

Commercial, HIM, NetResults

Approval duration increased to 12 months

Opioid IR

QL

Commercial, HIM, NetResults

Approval duration increased to 12 months

Oral Inhalers

PAQL

PA: Commercial
QL: Commercial, HIM, NetResults

*Added the branded generic for Arnuity (Fluticasone furoate Ellipta) as a target agent of PA program

Otezla

PAQL

Commercial, HIM, NetResults

*Added weight requirement (20 kg or greater) for pediatric patients 6 years of age and older with active psoriatic arthritis due to new FDA labeled indication
*Added conventional agent bypass if patient has previously used a biologic immunomodulator approved for the same indication
*Removed anthralin as an allowable/required conventional agent for psoriasis as there are no FDA approved anthralin treatments available on the market

Oxybate

PAQL

Commercial, HIM, NetResults

*Removed limitation of concomitant therapy of requested agents with another oxybate agent, Sunosi or Wakix

PAH

PAQL

Commercial, HIM, NetResults

*Removed obsolete agent 32mcg/48mcg of Tyvaso dpi maintenance kit as program target
*Adjusted criteria so that age criteria (required age within FDA labeling) does not apply to members who meet criteria through continuation of therapy

Parathyroid Hormone Analog Osteoporosis

PAQL

Commercial, HIM, NetResults

*Updated program to require step through generic Forteo for Bonsity requests
*Updated approval length to a minimum of 12 months

PCSK9 Inhibitors

PAQL

Commercial, HIM, NetResults

Removed requirement that patient use requested agents in combination with other lipid lowering therapies when used for homozygous familial hypercholesterolemia

Phenylketonuria

PA

Commercial, HIM, NetResults

*Updated baseline required phenylalanine blood level to a value of "greater than 360 micromol/L" for all patients requesting Kuvan, sapropterin or Sephience
*Updated initial approval length to 12 months

Phosphate Binders

STQL

ST: HIM
QL: HIM, NetResults

*Initial approval length increased to 12 months for all modules
*Quantity limit revised for all targets from a 90-day limit per 365 days to a 30-day supply at clinically-supported maximum daily dose for up to 12 months
*Removed “patient is NOT receiving dialysis” requirement from quantity limit criteria

PPI

ST/QL

ST: Commercial, NetResults
QL: Commercial, HIM, NetResults

*Quantity limit for Prilosec 2.5 mg Packet increased from 1/day to 2/day

Procysbi

PA

Commercial, HIM, NetResults

*Standardized language

Progesterones

PAQL

NetResults

*Standardized language and format

Pseudobulbar Affect

PAQL

NetResults

Approval duration increased to 12 months

Pyrukynd

PAQL

Commercial, HIM, NetResults

Approval duration increased to 12 months

Radicava

PAQL

Commercial, HIM, NetResults

Approval duration increased to 12 months

Rapid to Intermediate Acting Insulin

PAQL

Commercial, HIM, NetResults

Quantity limit program added to Commercial and HIM lines of business.

Recorlev

PAQL

Commercial, HIM, NetResults

*Removed requirement that patient's Cushing's syndrome diagnosis was confirmed persistent or recurrent
*Added criteria pathway for members with "another FDA labeled indication" to allow for any future FDA indications
*Removed the word "pituitary" from the requirement of inadequate response or not a candidate for "pituitary" surgery
*Added requirement that patient not be using the requested agent in combination with glucocorticoid replacement therapy for the requested indication
*Updated initial approval to 12 months

Retinoids

PA

Commercial, HIM, NetResults

*Removed Cabtreo as a Target Agent in this program
*If patient has an intolerance/hypersensitivity or contraindication to prerequisite agents, added requirement that this intolerance/hypersensitivity/contraindication must not be expected to occur with the requested agent

Retinoids

ST

Commercial, HIM

*Removed Cabtreo as a Target Agent in this program
*If patient has an intolerance/hypersensitivity or contraindication to prerequisite agents, added requirement that this intolerance/hypersensitivity/contraindication must not be expected to occur with the requested agent

SA Oncology

PAQL

Commercial, HIM, NetResults

*Removed obsolete target Zejula capsule from program
*Updated QL for Tabrecta from #120/30 days to #112/28 days due to needing to dispense in the original #56 count container
*Addition of Danziten, Nilotinib d-tartrate, and nilotinib (generic for Tasigna) to non-preferred agents for newly diagnosed Ph+CML in chronic phase alongside brand Tasigna
*Addition of Revlimid to list of brand agents that require step through generic equivalent prior to approval
*Increased approval to 12 months for all agents

Sensipar

PA

Commercial, HIM, NetResults

*Added continuation of therapy pathway for patients currently using Sensipar

Sohonos

PAQL

Commercial, HIM, NetResults

*Updated day supply for all strengths of Sohonos

Strensiq

PA

Commercial, HIM, NetResults

*Increased initial approval to 12 months

Sucraid

PAQL

NetResults

*Added criteria requirement that patient's age be within FDA labeling or there is support for use in patient's age (for patients new to therapy)
*Increased initial approval to 12 months

Tezspire

PAQL

Commercial, HIM, NetResults

Approval duration increased to 12 months

Thrombopoietin Receptor Antagonists and Tavalisse

PAQL

Commercial, HIM, NetResults

*Added new target agent Wayrilz to program and added criteria for this agent
*Added criteria pathway for pediatric patients with persistent immune (idiopathic) thrombocytopenia (ITP) within initial criteria for Doptelet requests
*Limited requests for Doptelet Sprinkle to patients age 1 year to less than 6 years of age
*Updated approval lengths to 12 months

Topical Actinic Keratosis, Basal Cell Carcinoma, Genital Warts Agents

PAQL

NetResults

*Updated approval length for all agents/indications to six months
*Updated quantity limit for all agents to be per 180 days
*Removed obsolete agent, fluorouracil 1% cream

Topical Antibiotics and Combinations

ST

Commercial

*Program removed from NetResults and HIM lines of business
*Added Cabtreo (brand) as a Target Agent
*Removal of Veltin from program
*For patients that have an intolerance/hypersensitivity or contraindication to prerequisite agents, added the requirement that this intolerance/hypersensitivity or contraindication is "not expected to occur with the requested agent"

Topical Antifungals, itraconazole, terbinafine

PAQL

NetResults

*Removed obsolete agent, itraconazole tablets, as target in program
*Removed requirement for needing to have an additional diagnosis or complication to the diagnosis of onychomycosis
*Added "biopsy" to the lab test options for diagnosing onychomycosis
*Added criteria pathway for members with "another FDA labeled indication" or "compendia supported indications" for members requesting Jublia, ciclopirox, or tavaborole
*Requirement that patient must step through an oral antifungal agent now applies to all indications for members requesting Jublia, ciclopirox, or tavaborole
*Added prerequisite requirement of amphotericin B prior to use of Sporanox or Tolsura for diagnosis of aspergillosis
*For diagnoses of blastomycosis, histoplasmosis, disseminated non-meningeal histoplasmosis, chronic cavitary pulmonary disease, oropharyngeal and esophageal candidiasis, added requirement that patient must be using the correct dosage form of Sporanox (if requesting Sporanox), as defined in labeling
*For use in "prophylaxis against invasive aspergillosis," patients requesting Sporanox and Tolsura must have one of the following: lung transplant, hematologic disorder with poorly functioning neutrophils, acute leukemia with repeat and/or prolonged neutropenia, or a history of invasive aspergillosis prior to transplantation
*Patient must now step through generic equivalent prior to being approved for brand name Sporanox or Tolsura
*Updated approval length to a minimum of 6 months for itraconazole and terbinafine
*For Tolsura, when used for FDA-approved indications, added requirement that age must be within age allowed within FDA labeling

Topical Corticosteroids

QL

Commercial, HIM, NetResults

*Removed obsolete products: flurandrenolide 0.05% ointment, flurandrenolide 0.025% Cream, Impeklo Lotion, Prednicarbate 0.1% ointment, Verdeso foam

Topical Doxepin

PAQL

NetResults

*For diagnosis of atopic dermatitis, added criteria requiring current and ongoing use of topical emollients and good skin care practices
*Moved the criteria point limiting use to a maximum of 8 days of therapy to only apply to the FDA labeled indications
*Added requirement that patient not be using the requested agent with another topical doxepin agent
*Updated approval length to a minimum of six months

Topical Estrogen

QL

NetResults

*Removed duplicate wording

Topical Lidocaine

PAQL

NetResults

*Removed obsolete agent, Synera, as target agent in program

Topical NSAID

STQL

ST: Commercial, HIM, NetResults
QL: Commercial, HIM, NetResults

*Standardized language and format

Topiramate ER

PAQL

NetResults

If using for an FDA-approved indication, added criteria requirement that patient age is supported for use in FDA labeling

Transmucosal Immediate Release Fentanyl

PAQL

PA: NetResults
QL: Commercial, HIM, NetResults

Approval duration increased to 12 months

Triptans

STQL

Commercial, HIM, NetResults

*Addition of double step for Symbravo. Requires a step through rizatriptan + meloxicam used in combination AND another generic triptan and meloxicam used in combination.

Tryngolza

PAQL

Commercial, HIM, NetResults

Approval duration increased to 12 months

Urea Cycle Disorders

PA

NetResults

*Standardized language

Urinary Incontinence

STQL

ST: Commercial
QL: NetResults

Removed ST program from HIM line of business

Verkazia

PAQL

Commercial, HIM, NetResults

Approval duration increased to 12 months

Vijoice

PAQL

NetResults

Approval duration increased to 12 months

VMAT Inhibitors

PAQL

Commercial, HIM, NetResults

Approval duration increased to 12 months

Voxzogo

PAQL

NetResults

* Removed requirement that the requested agent be used to increase linear growth

Weight Loss Agents

PAQL

Commercial, HIM, NetResults

Approval duration increased to 12 months

Weight Management

PAQL

Commercial, HIM, NetResults

*For diagnosis of noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH), removed allowance for stage F1 fibrosis
*For diagnosis of MASH, removed BMI requirements
*Updated criteria for MASH to require diagnosis be confirmed by either a liver biopsy or two of the following: FIB-4 score, Vibration-controlled transient elastography (VCTE), Enhanced liver fibrosis (ELF) score, and Magnetic resonance elastography (MRE)
*Updated initial approval to 12 months

Xolair

PA

Commercial, HIM, NetResults

Approval duration increased to 12 months

Yorvipath

PAQL

Commercial, HIM, NetResults

*Added disallowance for use in combination with teriparatide and Tymlos
*Increased initial approval to 12 months

Zeposia

PAQL

Commercial, HIM, NetResults

*Updated criteria to allow bypass of conventional agent requirements if patient has previously used the requested agent
*Simponi requests for ulcerative colitis: Removed note requiring trial and failure of an adalimumab product prior to use