CP.PHAR.442

Fedratinib (Inrebic)

12/1/2026

4Q 2026 annual review: for myeloid/lymphoid neoplasms with eosinophilia removed redirection to Jakafi per NCCN and specialist feedback; references reviewed and updated.

CP.PHAR.808

Gedatolisib (Revtorpyk)

12/1/2026

Policy created

CP.PHAR.753

Gemcitabine Intravesical System (Inlexzo)

12/1/2026

4Q 2026 annual review: added ICHRA line of business; added option for use in NMBIC with Ta or T1 papillary tumors per NCCN; references reviewed and updated.

CP.PHAR.171

Goserelin Acetate (Zoladex)

12/1/2026

4Q 2026 annual review: added ICHRA line of business; for ovarian cancer, salivary gland tumors, and uterine sarcoma added requirement for age ≥ 18 years; per NCCN compendium for ovarian cancer added requirement prescribed as a single agent; per NCCN compendium for salivary gland tumors added requirement prescribed as a single agent or in combination with abiraterone and prednisone; references reviewed and updated.

CP.PHAR.809

Iberdomide (Zenbexus)

12/1/2026

Policy created

CP.PHAR.754

Imlunestrant (Inluriyo)

12/1/2026

4Q 2026 annual review: added recurrent unresectable as additional qualifier option and added option for use in combination with Verzenio per NCCN; added ICHRA line of business; references reviewed and updated.

CP.PHAR.131

Infertility and Fertility Preservation

12/1/2026

4Q 2026 annual review: added ICHRA line of business; removed each states specific evidence of coverage language (EOC) and instead added language to refer to plan specific EOC document for benefit coverage; for female infertility and fertility preservation, added criterion that member is premenopausal; added off-label criteria for steroid-refractory acute graft-versus-host disease as supported by NCCN; references reviewed and updated,

CP.PHAR.137

Ivosidenib (Tibsovo)

12/1/2026

4Q 2026 annual review: for MDS, revised “disease progression, no response, or intolerance to prior systemic treatment” to “Prescribed as subsequent therapy,” added requirement for lower-risk MDS to apply to this revision, and added requirement for either clinically relevant thrombocytopenia/neutropenia or symptomatic anemia per NCCN; for cholangiocarcinoma, added option for unresectable disease per NCCN; for chondrosarcoma, added option for metastatic chondrosarcoma and monotherapy use requirement per NCCN; for gliomas, added option for other high-grade glioma per NCCN; added ICHRA line of business; references reviewed and updated.

CP.PHAR.79

Lapatinib (Tykerb)

12/1/2026

4Q 2026 annual review: removed off-label criteria for colorectal cancer as Tykerb was removed as a treatment option in NCCN guidelines Colon Cancer version 1.2026; added off-label criteria for sellar tumors, intracranial and spinal ependymoma (excluding subependymoma),and NF2-related progressive or symptomatic vestibular schwannoma (central nervous system cancers) per NCCN; added lapatinib to medically necessary statement as generic requires prior authorization; added ICHRA line of business; references reviewed and updated.

CP.PHAR.414

Larotrectinib (Vitrakvi)

12/1/2026

4Q 2026 annual review: added ICHRA line of business; clarified policy applies to generic Larotrectinib; removed requirement that request does not exceed health-plan approved quantity limit; updated Appendix E with revised language for Tennessee; references reviewed and updated.

CP.PHAR.695

Lazertinib (Lazcluze)

12/1/2026

4Q 2026 annual review: added options for Lazcluze monotherapy and for combination Lazcluze+Rybrevant as subsequent therapy following Tagrisso-based therapy per NCCN; added ICHRA line of business; references reviewed and updated.

CP.PCH.58

Lebrikizumab (Ebglyss)

12/1/2026

4Q 2026 annual review: for initial and continued therapy, added option for every 8-week maintenance dosing per PI; added Nemluvio as an example of biologic medication for which concurrent use is excluded; references reviewed and updated.

CP.PHAR.596

Lecanemab-irmb (Leqembi, Leqembi Iqlik)

12/1/2026

4Q 2026 annual review: added the new indication for Leqembi Iqlik for treatment initiation; references reviewed and updated.

CP.PHAR.138

Lenvatinib (Lenvima)

12/1/2026

4Q 2026 annual review: added ICHRA line of business; for DTC, added option for use in locoregionally invasive disease and after thyroidectomy; for RCC, added option for use as a single agent as subsequent therapy if RCC histology is clear cell per NCCN; references reviewed and updated.

CP.PCH.53

Leuprolide Acetate (Lupron Eligard Lupaneta Pack Fensolvi Camcevi Vabrinity)

12/1/2026

4Q 2026 annual review: added requirement for age ≥ 18 years for salivary gland tumors and uterine sarcoma; per NCCN compendium for breast cancer added requirement that member is premenopausal or male and prescribed in combination with endocrine therapy; for infertility/fertility preservation coverage added the following clarification: ‘HIM line of business: pharmacy benefit coverage restrictions by state. Please refer to plan specific evidence of coverage (EOC) document for benefit coverage.’; added S9560 HCPCS code; references reviewed and updated.

CP.PHAR.682

Levacetylleucine (Aqneursa)

12/1/2026

4Q 2026 annual review: updated NPC diagnostic criterion to require confirmation by biallelic pathogenic variants in NPC1 or NPC2 gene per updated international consensus guidelines; references reviewed and updated.

CP.PHAR.507

Lomustine (Gleostine)

12/1/2026

4Q 2026 annual review: added ICHRA line of business; clarified policy/criteria applies to generic lomustine; for all indications, clarified member must use generic lomustine for brand Gleostine requests; references reviewed and updated.

CP.PHAR.802_PEPP

Medoretgene parvec (AAV-AIPL1)_PEPP

12/1/2026

Policy created pre-emptively

CP.PHAR.164

Miglustat (Zavesca)

12/1/2026

Updated NPC diagnostic criterion to require confirmation by biallelic pathogenic variants in NPC1 or NPC2 gene per updated international consensus guidelines.

CP.PHAR.558

Mitapivat (Pyrukynd, Aqvesme)

12/1/2026

4Q 2026 annual review: for PK deficiency, revised initial approval duration to 12 months; added ICHRA line of business; references reviewed and updated.

CP.PHAR.139

Mogamulizumab-kpkc (Poteligeo)

12/1/2026

4Q 2026 annual review: for ATLL initial therapy, removed “prescribed as a single agent” and added option for use in combination with CHOP per NCCN; added ICHRA line of business; references reviewed and updated.

CP.PHAR.654

Momelotinib (Ojjaara)

12/1/2026

4Q 2026 annual review: added ICHRA line of business; added off-label criteria for myeloid or lymphoid neoplasm with eosinophilia and Janus kinase 2 arrangement per NCCN category 2A recommendation; references reviewed and updated.

CP.PHAR.461

Nadofaragene firadenovec-vncg (Adstiladrin)

12/1/2026

4Q 2026 annual review: increased initial and continued therapy approval duration to 12 months for this maintenance medication for a chronic condition; references reviewed and updated.

CP.PHAR.365

Neratinib (Nerlynx)

12/1/2026

4Q 2026 annual review: for breast cancer, added off-label criteria for HER2-negative disease per NCCN; added ICHRA line of business; references reviewed and updated.

HIM.PA.152

Nitazoxanide (Alinia)

12/1/2026

4Q 2026 annual review: added ICHRA line of business; added option for extended off-label dosing requests for the treatment of cryptosporidiosis in an immunocompromised patient per IDSA/CDC/NIH guidelines; references reviewed and updated.

HIM.PA.33

No Coverage Criteria

12/1/2026

4Q 2026 annual review: for FDA-approved doses, added requirement that request does not exceed health plan-approved quantity limit per CDPA request; updated Appendix E with revised language for Tennessee; added Nevada to Appendix F; added ICHRA line of business; references reviewed and updated.

CP.PHAR.684

Nogapendekin alfa inbakicept-pmln (Anktiva)

12/1/2026

4Q 2026 annual review: extended initial approval duration from 6 months to 12 months for this chronic condition; references reviewed and updated.

CP.PHAR.305

Obinutuzumab (Gazyva)

12/1/2026

4Q 2026 annual review: separated FL criteria from “B-Cell Lymphomas and Tumors with B-Cell Predominance” and renamed existing criteria “Additional NCCN Recommended Uses (off-label);” for CLL/SLL, added treatment option combinations for first-line therapy and histologic (Richter) transformation per NCCN; for FL, added NCCN-supported regimens for second-line and subsequent therapy; added indication of Waldenstrom macroglobulinemia/lymphoplasmacytic lymphoma per NCCN; for mantle cell lymphoma, added option for use as a substitute for rituximab at provider’s discretion per NCCN; added ICHRA line of business; references reviewed and updated.

HIM.PA.154

Off-label Policy

12/1/2026

4Q 2026 annual review: updated Appendix E with revised language for Tennessee; added Nevada to Appendix H; added ICHRA line of business; references reviewed and updated.

CP.PHAR.536

Ophthalmic Riboflavin (Photrexa, Photrexa Viscous, Epioxa HD, Epioxa)

12/1/2026

Added Epioxa HD and Epioxa to criteria per local market request.

CP.PHAR.810

Oveporexton (Orzeyful)

12/1/2026

Policy created

HIM.PA.173

Palbociclib (Ibrance)

12/1/2026

4Q 2026 annual review: for breast cancer, added option for combination use with fulvestrant and Revtorpyk per NCCN; added bypass to Kisqali and Verzenio redirection for combination use with Revtorpyk; added option for combination use with Etcamah if disease is ESR1 mutated per Etcamah’s FDA labeled indication; added off-label criteria for uterine neoplasms per NCCN; references reviewed and updated.

CP.PHAR.696

Palopegteriparatide (Yorvipath)

12/1/2026

4Q 2026 annual review: added requirement that member does not have acute post-surgical hypoparathyroidism; added ICHRA line of business; references reviewed and updated.

CP.PHAR.321

Panitumumab (Vectibix)

12/1/2026

4Q 2026 annual review: added ICHRA line of business; added off-label small bowel adenocarcinoma and appendiceal neoplasms and cancers per NCCN; for CRC per NCCN, removed specification for BRAF V600E mutation positive disease for use in combination with Braftovi, removed specification for KRAS G12C positive disease for use in combination with Lumakras or Krazati; references reviewed and updated.

CP.PHAR.513

Plasminogen (Ryplazim)

12/1/2026

4Q 2026 annual review: revised diagnostic criteria to clarify “PLG mutation” as “biallelic mutations in the PLG gene,” to require signs/symptoms of C-PGLD, and to meet either the plasminogen activity level ≤ 45% or the biallelic mutations in PLG gene as a diagnostic criterion; added ICHRA line of business; references reviewed and updated.

CP.PHAR.803_PEPP

Povetacicept (ALPN-303)_PEPP

12/1/2026

Policy created pre-emptively

CP.PHAR.646

Quizartinib (Vanflyta)

12/1/2026

4Q 2026 annual review: added single agent therapy requirement for relapsed/refractory AML per NCCN; for continued therapy, revised “AML” to “a covered indication;” added ICHRA line of business; references reviewed and updated.

CP.PHAR.756

Remibrutinib (Rhapsido)

12/1/2026

4Q 2026 annual review: for antihistamine trials, revised required dose from maximum “indicated” to “tolerated” to allow for up to 4-fold standard dosing per practice guidelines; added ICHRA line of business; references reviewed and updated.

CP.PHAR.667

Repotrectinib (Augtyro)

12/1/2026

4Q 2026 annual review: added ICHRA line of business; for NTRK fusion-positive cancer, added option for use in unresectable disease and simplified criteria by removal of requirement that disease has progressed following treatment with no satisfactory alternative therapy; clarified solid tumors examples Appendix D per NCCN compendium; references reviewed and updated.

CP.PHAR.647

Resmetirom (Rezdiffra)

12/1/2026

4Q 2026 annual review: revised exclusion for concurrent prescribing with Wegovy to concurrent initiation with Wegovy for initial criteria per updated guidelines; revised failure of ≥ 6-month trial of Wegovy to “Inadequate response to ≥ 12-month of Wegovy” per updated guidelines; removed concurrent prescribing exclusion from continued therapy criteria; added that member has not progressed to cirrhosis for continued therapy; added ICHRA line of business; references reviewed and updated.

CP.PHAR.334

Ribociclib (Kisqali, Kisqali Femara)

12/1/2026

4Q 2026 annual review: for breast cancer, added option to be prescribed in combination with Etcamah if disease is ESR1 mutated per Etcamah’s FDA labeled indication; added ICHRA line of business; references reviewed and updated.

CP.PHAR.314

Romidepsin (Istodax)

12/1/2026

4Q 2026 annual review: for initial therapy, added bypass of failure of one prior systemic therapy for subcutaneous panniculitis-like T-cell lymphoma per NCCN; added ICHRA line of business; references reviewed and updated.

CP.PHAR.648

Rozanolixizumab-noli (Rystiggo)

12/1/2026

4Q 2026 annual review: for gMG, added Imaavy and Uplizna to the list of therapies that Rystiggo should not be prescribed concurrently with; added ICHRA line of business; references reviewed and updated.

CP.PHAR.698

Seladelpar (Livdelzi)

12/1/2026

4Q 2026 annual review: added ICHRA line of business; added requirement that Livdelzi is not prescribed concurrently with Iqirvo to initial and continued therapy to prevent duplicate therapy; added requirement that member does not have decompensated cirrhosis (e.g., ascites, variceal bleeding, hepatic encephalopathy) per prescribing information; references reviewed and updated.

CP.PHAR.649

Talquetamab-tgvs (Talvey)

12/1/2026

4Q 2026 annual review: added ICHRA line of business; added option to be prescribed as bridge to BCMA CAR-T therapy per NCCN; references reviewed and updated.

CP.PMN.313

Tebipenem pivoxil (Utebzi)

12/1/2026

Policy created

CP.PHAR.324

Temsirolimus (Torisel)

12/1/2026

4Q 2026 annual review: for soft tissue sarcoma, added option for pediatric rhabdomyosarcoma indication per NCCN; added age bypass for pediatric rhabdomyosarcoma; added ICHRA line of business; references reviewed and updated.

CP.PHAR.561

Tisotumab vedotin-tftv (Tivdak)

12/1/2026

4Q 2026 annual review: removed monotherapy requirement from continued therapy; added ICHRA line of business; references reviewed and updated.

CP.PHAR.175

Triptorelin pamoate (Trelstar, Triptodur)

12/1/2026

4Q 2026 annual review: added ICHRA line of business; for breast cancer, salivary gland tumors, and uterine sarcoma added requirement for age ≥ 18 years; per NCCN compendium for breast cancer added requirement that member is premenopausal or male and prescribed in combination with endocrine therapy; references reviewed and updated.

CP.PHAR.439

Valrubicin (Valstar)

12/1/2026

4Q 2026 annual review: added ICHRA line of business; removed specification of CIS disease; added option for use as subsequent treatment for muscle invasive disease in combination with TURBT per NCCN; added option for use in CIS, Ta, or T1 local recurrence or persistent disease in a preserved bladder for disease treated with curative intent per NCCN; references reviewed and updated.

CP.PHAR.129

Venetoclax (Venclexta)

12/1/2026

4Q 2026 annual review: for CLL/SLL, added Brukinsa as first-line therapy option, removed requirement for absence of del(17p)/TP53 mutation, added both Brukinsa and Calquence as subsequent therapy combination options, and added additional treatment options for histologic (Richter) transformation per NCCN; for mantle cell lymphoma that is positive for TP53 mutation, replaced combination therapy Gazyva + Imbruvica with combination therapy Gazyva + Brukinsa per NCCN; for AML, expanded therapy options for inclusion of Inqovi and for relapsed/refractory disease, therapy-related AML, and poor-risk AML per NCCN; for BPDCN, removed option for palliative intent of systemic disease and added option for Venclexta prescribed as treatment induction per NCCN; for systemic light chain amyloidosis, added requirement for t(11;14) translocation per NCCN; for MDS, expanded combination therapy options to include Inqovi per NCCN; for Philadelphia chromosome negative B-cell ALL, added option for relapsed/refractory disease per NCCN; for ALL, added indication option for Philadelphia chromosome-positive B-cell ALL per NCCN; for continued therapy for AML, replaced named combination therapy agents with “combination therapy;” added ICHRA line of business; references reviewed and updated.

CP.PHAR.699

Vorasidenib (Voranigo)

12/1/2026

4Q 2026 annual review: added monotherapy requirement to continued therapy; added ICHRA line of business; references reviewed and updated.

CP.PHAR.804_PEPP

Zeleciment rostudirsen (DYNE-251)_PEPP

12/1/2026

Policy created pre-emptively

CP.PHAR.811

Zidesamtinib (Jideytro)

12/1/2026

Policy created

AR.QC.PMN.214

Continuous Glucose Monitors

12/1/2026

4Q 2026 annual review: added requirement that age is in line with the FDA-approved age for the requested product; for continued therapy requests for a new receiver, modified reasonable/useful lifetime from 5 to 3 years per various CGM user guides; incorporated existing quantity limit for receivers from approval duration into criteria; references reviewed and updated.