RT4: updated to include withdrawal of previously FDA-approved indication for urothelial cancer and changed to off-label as the use remains NCCN supported; added provider attestation criterion acknowledging FDA withdrawal; added withdrawal information in Appendix D.
CP.PHAR.593
Delandistrogene moxeparvovec-rokl (Elevidys)
6/01/2025
Added requirement for current documentation (within the last 90 days) of member’s body weight (in kg).
CP.PHAR.01
Omalizumab (Xolair)
06/01/2025
1Q 2025 annual review: for asthma initial approval criteria, added allowance for ER visit, removed intubation option for alignment purposes as a hospital admission would encompass intubation; for immune checkpoint inhibitor-related severe pruritis, added requirement for no response to 1 month of gabapentinoid therapy per NCCN; updated Appendix D to include information about atopic dermatitis; references reviewed and updated.
For IBS-C added step-wise redirection to Trulance.
CP.PHAR.220
Factor VIIa Recombinant (NovoSeven RT, SevenFact)
06/01/2025
1Q 2025 annual review: clarified that acquired hemophilia indication is applicable to NovoSeven RT only; references reviewed and updated.
CP.PHAR.368
Pemetrexed (Alimta, Pemfexy, Axtle)
06/01/2025
1Q 2025 annual review: added Commercial line of business; for cervical cancer, removed hematologist as prescriber option; added off-label indications for vaginal cancer and non-nasopharyngeal cancers per NCCN; for continued therapy revised language from “has had at least one dose in the last 90 days” to our standard language of “received this medication for at least 30 days”; updated HCPCS code descriptions for [J9297 and J9323]; references reviewed and updated.
RT4: added newly approved Axtle to the policy.
For questions about QualChoice Medical Coverage Policies, please contact your Provider Relations Representative at 800.235.7111 or 501.228.7111, Monday through Friday, 8:00 a.m. to 5:00 p.m.
