For initial approval criteria, clarified number of failed agents from hormonal therapy products to two formulary estrogen products.
HIM.PA.SP69
Dupilumab (Dupixent)
03/01/25
Added newly approved COPD indication to criteria. For prurigo nodularis initial approval criteria, updated diagnosis criteria from “WI-NRS ≥ 7 on a scale of 0 to 10” to “Numeric rating scale > 7 on a scale of 0 (“no itch”) to 10 (“worst imaginable itch”) (e.g., Peak Pruritus Numeric Rating Scale, Worst Itch-Numeric Rating Scale)” to align with Nemluvio criteria.
Removed redirection to Pancreaze; apply redirection to Creon and Zenpep for Pancreaze requests.
HIM.PA.174
Tenapanor (Ibsrela, Xphozah)
03/01/25
For IBS-C added step-wise redirection to Trulance.
CP.PHAR.207
Glycerol Phenylbutyrate (Ravicti)
03/01/25
Added redirection to generic sodium phenylbutyrate followed by redirection to Pheburane for requests for continuation of therapy.
CP.PHAR.76
Nilotinib (Tasigna, Danziten)
03/01/25
Added newly approved Danziten to policy for CML only; for CML, added age requirement ≥ 1 year for Tasigma per Prescribing Information; for ALL, added age requirement ≥ 15 years per NCCN.
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