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Medical Policy Number
| Medical Policy Name | Effective Date of Change | Description of Changes |
|---|
|
| Bendamustine | 03/01/23 | Added Vivimusta to coverage criteria; updated all coverage criteria. |
|
| Continuous Glucoe Monitoring | 07/01/23 | Noted that K0553 and K0554 were deleted as of 12/31/2022. |
|
| Bevacizumab | 03/01/23 | Updated to include Q5126. |
|
| Adcetris | 05/01/23 | Updated criteria for classical Hodgkins for adults and added criteria for classical Hodgkins for peds/adolescents. Updated criteria for T-cell lymphoma, Primary Cutaneous CD30+ T-cell Lymphomproliferative Disorder, and Mycosis Fungoides/Sezary Syndrome. Added continuation criteria for all covered diagnoses. |
|
| Imfinzi | 05/01/23 | Updated criteria for NSCLC, extensive-stage small cell lung cancer, biliary tract cancer, and hepatocellular carcinoma. Added continuation criteria for all coverage criteria. |
|
| Libtayo | 05/01/23 | Updated CSCC criteria and added criteria for basal cell carcinoma and non-small cell lung cancer (NSCLC). |
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| Trastuzumab | 05/01/23 | Updated preferred biosimilars; added criteria for off-label uses colorectal cancer and salivary gland tumor. |
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| Amvuttra | 03/01/23 | Amvuttra is used in the treatment of the polyneuropathy of hereditary transthyretin-mediated (hATTR) amyloidosis in adults. It is covered under the medical benefit and requires prior authorization. |
