CP.PHAR.146

Deferoxamine (Desferal)

9/1/2026

3Q 2026 annual review: added ICHRA line of business; revised approval continued therapy duration for Commercial from 12 months to standard injectable authorization of “6 months or to the member’s renewal date, whichever is longer”; references reviewed and updated.

CP.PHAR.173

Leuprolide Acetate (Lupron, Eligard, Lupaneta Pack, Fensolvi, Camcevi, Vabrinty

9/1/2026

Added off-label use for female infertility per plan request.

CP.PHAR.177

Ecallantide (Kalbitor)

9/1/2026

3Q 2026 annual review: added ICHRA line of business; extended Medicaid and HIM initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition; references reviewed and updated.

CP.PHAR.202

C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest)

9/1/2026

3Q 2026 annual review: extended Medicaid initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition; references reviewed and updated.

CP.PHAR.241

Abatacept (Orencia)

9/1/2026

Per June SDC: for PsA, removed criteria requiring use of Taltz.

CP.PHAR.253

Golimumab (Simponi, Simponi Aria)

9/1/2026

RT4: added FDA approved biosimilars Immgolis and Immgolis Intri to criteria.

Per June SDC: for AS and PsA, removed criteria requiring use of Taltz.

CP.PHAR.264

Ustekinumab (Stelara)

9/1/2026

RT4: for Stelara/ustekinumab, updated CD criteria with pediatric extension for ages 2 to 17 years per prescribing information; added HCPCS code Q5164.

Per June SDC: for pediatric CD initial approval criteria, for brand Stelara requests, added criteria requiring use of preferred adalimumab products and unbranded ustekinumab; for continued therapy, for brand Stelara requests, added criteria requiring use of unbranded ustekinumab.

CP.PHAR.297

Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix), Filgrastim-aafi (Nivestym), Filgrastim-ayow (Releuko), Filgrastim-txid (Nypozi)

9/1/2026

3Q 2026 annual review: added NCCN Compendium supported use for neutropenia following CAR T-cell therapy or lymphocyte engager-therapy; references reviewed and updated.

CP.PHAR.303

Brentuximab Vedotin (Adcetris)

9/1/2026

3Q 2026 annual review: per NCCN – for cHL in adults, removed option for Deauville score 4-5 and revised age 18-61 to age 18-60 for use as a component of BrECADD and added option that member is unfit for intensive therapy for use in combination with dacarbazine or nivolumab; for T-cell lymphomas, added option for use in combination with CHEP for PTCL; for B-cell lymphomas, added that DLBCL includes histologic transformation of indolent lymphomas to DLBCL and removed requirement that disease is CD30-positive; added ICHRA line of business; for all indications, extended initial approval durations for Medicaid/HIM from 6 to 12 months and revised all approval durations for Commercial to “6 months or to the member’s renewal date, whichever is longer”; references reviewed and updated.

CP.PHAR.310

Daratumumab (Darzalex), Daratumumab/Hyaluronidase-fihj (Darzalex Faspro)

9/1/2026

3Q 2026 annual review: added NCCN Compendium supported use for MM in combination with Tecvayli; added additional use for systemic light chain amyloidosis in combination with Venclexta, clarified use in combination with lenalidomide and dexamethasone should be for relapsed/refractory previously treated disease, and for use as single agent therapy in newly diagnosed disease corrected to require no significant neuropathy; added criteria set for HIV-related plasmablastic lymphoma; added ICHRA line of business; references reviewed and updated.

CP.PHAR.312

Blinatumomab (Blincyto)

9/1/2026

3Q 2026 annual review: revised option for adult consolidation therapy for Ph+ disease to specify disease must be refractory to TKIs per NCCN; added ICHRA line of business; extended initial approval duration for Medicaid/HIM from 6 to 12 months and revised all approval durations for Commercial to “6 months or to the member’s renewal date, whichever is longer”; references reviewed and updated

CP.PHAR.322

Pembrolizumab, Pembrolizumab/Berahyaluronidase Alfa-pmph (Keytruda, Keytruda Qlex)

9/1/2026

3Q 2026 annual review: added ICHRA line of business; for urothelial carcinoma and MPM, removed requirement for locally advanced, relapsed, or metastatic disease; for NSCLC, added option to be prescribed as single-agent for those who have received previous adjuvant chemotherapy or neoadjuvant chemotherapy with pembrolizumab; for MSI-H/dMMR, added option for neoadjuvant systemic therapy for gallbladder cancer, gastric cancer, adenocarcinoma GEJ, and small bowel adenocarcinoma; for off-label anal carcinoma and vulvar cancer, added option to be prescribed in combination with paclitaxel and cisplatin/carboplatin; for off-label soft tissue sarcoma subtypes, added option to be prescribed as single-agent for cutaneous angiosarcoma or dedifferentiated liposarcoma and as neoadjuvant or adjuvant therapy for UPS related sarcomas; for off-label vaginal cancer, added requirement for unresectable, metastatic or recurrent PD-L1-positive (CPS ≥ 1) disease; added the following off-label indications per NCCN: appendiceal neoplasms and cancers, recurrent conventional chordoma (including chondroid), dedifferentiated chondrosarcoma; CLL/SLL with histologic (Richter) transformation, and malignant histiocytic neoplasm; references reviewed and updated.

Per June SDC, added redirection to Imfinzi for BTC.

CP.PHAR.396

Lanadelumab-fylo (Takhzyro)

9/1/2026

3Q 2026 annual review: extended Medicaid initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition; references reviewed and updated.

CP.PHAR.41

Enfuvirtide (Fuzeon)

9/1/2026

3Q 2026 annual review: added ICHRA line of business; extended Medicaid and HIM initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition; references reviewed and updated.

CP.PHAR.415

Ravulizumab-cwvz (Ultomiris)

9/1/2026

3Q 2026 annual review: for gMG, added Imaavy and Uplizna to the list of therapies that Ultomiris should not be prescribed concurrently with; added ICHRA line of business; for all indications, extended initial approval durations for Medicaid/HIM from 6 to 12 months and revised all approval durations for Commercial to “6 months or to the member’s renewal date, whichever is longer” for this maintenance medication for a chronic condition; removed 300 mg/30 mL IV vial and SC injection dosage form per prescribing information and updated dosing requirements accordingly in criteria; references reviewed and updated.

CP.PHAR.424

Fulvestrant (Faslodex Injection)

9/1/2026

3Q 2026 annual review: for ovarian, fallopian tube, and primary peritoneal cancers, expanded cancer stage range from just low-grade serous carcinoma to IC-IV per NCCN; for endometrial carcinoma, added option for combination therapy with Verzenio for ER-positive tumors per NCCN; for uterine sarcoma, clarified disease must be HR-positive and removed criteria that fulvestrant must be prescribed in specific scenarios per NCCN; revised initial and continued approval durations for all non-Commercial lines of business from 6 months to 12 months; added ICHRA line of business; references reviewed and updated.

CP.PHAR.425

Metreleptin (Myalept)

9/1/2026

3Q 2026 annual review: added ICHRA line of business; extended Medicaid and HIM initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition; references reviewed and updated.

CP.PHAR.426

Risankizumab-rzaa (Skyrizi)

9/1/2026

Per June SDC: for PsO and PsA, removed criteria requiring use of Taltz.

CP.PHAR.433

Polatuzumab Vedotin-piiq (Polivy)

9/1/2026

3Q 2026 annual review: added off-label coverage for mantle cell lymphoma and Burkitt lymphoma per NCCN; for other lymphomas, added option for combination use with Columvi or with GemOx and rituximab for non-transplant/CAR T-cell candidates per NCCN; incorporated existing cycle limitations from approval duration into criteria; added ICHRA line of business; for Medicaid/HIM, revised initial approval duration from 6 to 12 months; for Commercial, revised initial/continued approval durations from 6/12 months to “6 months or to the member’s renewal date, whichever is longer”; references reviewed and updated

CP.PHAR.463

Satralizumab-mwge (Enspryng)

9/1/2026

3Q 2026 annual review: added ICHRA line of business; extended initial approval durations for Medicaid/HIM from 6 to 12 months and revised all approval durations for Commercial to “6 months or to the member’s renewal date, whichever is longer” for this maintenance medication for a chronic condition; references reviewed and updated.

CP.PHAR.495

Mitomycin Instillation Solution (Jelmyto, Zusduri)

9/1/2026

3Q 2026 annual review: for NMIBC, removed requirement for low-grade disease and TURBT and added option for high risk disease per NCCN; added off-label indication of MIBC per NCCN; added ICHRA line of business; references reviewed and updated.

CP.PHAR.500

Lurbinectedin (Zepzelca)

9/1/2026

3Q 2026 annual review: for continued therapy, removed single-agent requirement; added ICHRA line of business; references reviewed and updated.

CP.PHAR.511

Evinacumab-dgnb (Evkeeza)

9/1/2026

Per 2026 guideline updates: revised ezetimibe requirements to ages ≥ 10 years; revised statin requirement to ages ≥ 7 years; revised LDL requirements to ≥ 100 mg/dL for pediatric population ≥ 7 years; removed ‘very high risk’ qualifier from adult LDL requirement; modified moderate or low intensity statin requirement therapy from requiring previous use of one high intensity statin and LDL remained ≥ 70 mg/dL to LDL goal was not achieved to reflect differing LDL goals based on specific indication; revised Commercial initial and continued therapy approval duration from 12 months to standard duration for injectables, 6 months or to the member’s renewal date, whichever is longer.

CP.PHAR.524

Pegcetacoplan (Empaveli, Syfovre)

9/1/2026

3Q 2026 annual review: added ICHRA line of business; for PNH and C3G/primary IC-MPGN, revised all approval durations to “6 months or to the member’s renewal date, whichever is longer” for Commercial and initial approval durations from 6 to 12 months for Medicaid and HIM; references reviewed and updated.

CP.PHAR.525

Vosoritide (Voxzogo)

9/1/2026

Per June SDC, added requirement that member will not have limb-lengthening surgery during treatment; added ICHRA line of business.

CP.PHAR.540

Dostarlimab-gxly (Jemperli)

9/1/2026

3Q 2026 annual review: per NCCN – for solid tumors, revised to require use as subsequent therapy for pancreatic adenocarcinoma, added option for use as neoadjuvant therapy for gastric, colon, rectal, or small bowel adenocarcinoma, esophageal, esophagogastric junction, appendiceal cancers, and added option for use as induction systemic therapy for esophageal and esophagogastric junction cancers; for anal carcinoma, added options for use in combination with paclitaxel and carboplatin; added ICHRA line of business; for all indications, extended initial approval durations for Medicaid/HIM from 6 to 12 months and revised all approval durations for Commercial to “6 months or to the member’s renewal date, whichever is longer”; references reviewed and updated.

CP.PHAR.542

Talimogene laherepvec (Imlygic)

9/1/2026

3Q 2026 annual review: added ICHRA line of business; for all indications, extended initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition; for MCC, added requirement for disease progression following treatment with anti-PD-1/PD-L1 therapy unless contraindication per NCCN compendium; references reviewed and updated.

CP.PHAR.544

Amivantamab-vmjw (Rybrevant), Amivantamab/Hyaluronidase-lpuj (Rybrevant Faspro)

9/1/2026

Q 2026 annual review: for initial approval criteria, added Rybrevant/Rybrevant Faspro is prescribed in combination with Lazcluze for leptomeningeal metastases per NCCN; added ICHRA line of business; added HCPCS code J9062 and removed codes C9399 and J9999; references reviewed and updated.

CP.PHAR.555

Efgartigimod Alfa-fcab, Efgartigimod/Hyaluronidase-qvfc (Vyvgart, Vyvgart Hytrulo)

9/1/2026

For CIDP, added ≥ 3 months duration to immune globulin therapy criterion to ensure adequate trial prior to advancing treatment; added ICHRA line of business.