Azacitidine (Onureg, Vidaza) (CP.PHAR.387)

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

Policy updates include:

• Added additional indication for Vidaza in pediatric patients aged 1 month and older with newly diagnosed JMML per updated prescribing information

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

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

Policy updates include:

• Added newly FDA-approved biosimilar Alymsys to policy

Edaravone (Radicava) (CP.PHAR.343)

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

Policy updates include:

• Added new oral suspension formulation

Fam-trastuzumab Deruxtecan-nxki (Enhertu) (CP.PHAR.456)

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

Policy updates include:

• Added criteria for new FDA-approved indication as 2nd line for breast cancer per PI
• Added criteria for 1st-line therapy for breast cancer in select patients per NCCN

GLP-1 receptor agonists (HIM.PA.53)

Ambetter

Policy updates include:

• Added newly FDA approved drug, Mounjaro

Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists (CP.PMN.183)

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

Policy updates include:

• Added newly FDA approved drug, Mounjaro

Inhaled Agents for Asthma and COPD (HIM.PA.153)

Ambetter

Policy updates include:

• Updated ArmonAir Digihaler per prescribing information for pediatric extension down to 4 years of age and older
• Added new 30 mcg strength

Ipilimumab (Yervoy) (CP.PHAR.319)

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

Policy updates include:

• Criteria added for new FDA approved indication of ESCC in combination with Opdivo
• For HCC, added additional option for prior use of Imfinzi and removed requirement for no previous treatment with a checkpoint inhibitor per latest NCCN guidelines.

Nivolumab (Opdivo) (CP.PHAR.121)

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

Policy updates include:

• Criteria added for new FDA approved indication for first-line use in ESCC in combination with Yervoy or with fluoropyrimidine- and platinum-containing chemotherapy
• For HCC, added additional options for prior use of Tecentriq+bevacizumab or Imfinzi and removed requirement for no previous treatment with a checkpoint inhibitor per latest NCCN guidelines.

Ravulizumab-cwvz (Ultomiris) (CP.PHAR.415)

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

Policy updates include:

• Criteria added for new FDA indication: gMG

Step Therapy (HIM.PA.109)

Ambetter

Policy updates include:

• Removed zolpidem tartrate ER and ramelteon from criteria

Viloxazine (Qelbree) (CP.PMN.264)

Ambetter

Policy updates include:

• Updated policy with FDA-labeled age expansion to include adults