Belzutifan (Welireg) (CP.PHAR.553)

Ambetter

Policy updates include:

• Added new Food and Drug Administration-approved indication of advanced renal cell carcinoma

Bevacizumab (Alymsys, Avastin, Avzivi, Mvasi, Vegzelma, Zirabev) (CP.PHAR.93)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Added newly Food and Drug Administration-approved biosimilar Avzivi to policy
• For ovarian cancers, added combination therapy with Zejula per National Comprehensive Cancer Network
• Created separate section for oncology – non-Food and Drug Administration-approved indications for pediatrics to include diffuse high-grade glioma

Binimetinib (Mektovi) (CP.PHAR.50)

Ambetter

Policy updates include:

• Added newly Food and Drug Administration-approved and National Comprehensive Cancer Network compendium supported use in non-small cell lung cancer in combination with Mektovi

Bosutinib (Bosulif) (CP.PHAR.105)

Ambetter

Policy updates include:

• Added new Food and Drug Administration approved pediatric age extension to 1 year old for chronic myelogenous leukemia
• Added new oral capsule formulation

Dextromethorphan-bupropion (Auvelity) (CP.PMN.284)

Ambetter

Policy updates include:

• Corrected criteria to remove individual Auvelity components use

Encorafenib (Braftovi) (CP.PHAR.127)

Ambetter

Policy updates include:

• Added newly Food and Drug Administration-approved and National Comprehensive Cancer Network compendium supported use in non-small cell lung cancer in combination with Mektovi

Entrectinib (Rozlytrek) (CP.PHAR.441)

Ambetter

Policy updates include:

• For neurotrophic tyrosine receptor kinase   solid tumors, updated age limit to > 1 month from ≥ 12 years per newly Food and Drug Administration-approved pediatric extension; updated recommended dosages
• Added new oral pellet formulation; for non-small cell lung cancer, removed exclusion for members who previously received ROS1 therapy per National Comprehensive Cancer Network and Food and Drug Administration

Faricimab-svoa (Vabysmo) (CP.PHAR.581)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Added newly Food and Drug Administration-approved indication of macular edema following retinal vein occlusion

Immune Globulins

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Added Alyglo to policy

Isavuconazonium (Cresemba

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

• Revised to reflect pediatric expansion for both indications
• For invasive aspergillosis, clarified that required trial of voriconazole only applies to age ≥ 2 years and updated Appendix B dosing regimens per voriconazole’s package insert

Pancrelipase (Creon, Pancreaze, Pertyze, Viokace, Zenpep) (CP.PCH.44)

Ambetter

Policy updates include:

• For Zenpep added new 60,000 USP unit strength

Patiromer (Veltassa) (CP.PMN.205)

Ambetter

Policy updates include:

• Newly Food and Drug Administration approved indication reflected with pediatric age extension down to 12 years of age
• Added new formulation of 1 gm powder pack

Pilocarpine (Vuity, Qlosi) (CP.PMN.270)

Ambetter

Policy updates include:

• Added newly approved agent Qlosi to criteria

Pirtobrutinib (Jaypirca) (CP.PHAR.620)

Ambetter

Policy updates include:

• Added new indication for chronic lymphocytic leukemia and small lymphocytic lymphoma  per updated prescribing information and National Comprehensive Cancer Network supported off-label uses