HCPCS code added [J9289]; RT4: updated FDA Approved Indication(s) section and criteria to reflect revised indication that limits use to tumors expressing PD-L1 (≥ 1) in combination with chemotherapy for unresectable advanced or metastatic ESCC in first-line setting and gastric cancer, GEJ cancer and esophageal adenocarcinoma (previously approved regardless of PD-L1 status); also for MSI-H or dMMR esophageal cancers, specified usage as perioperative therapy when prescribed as a single age, as induction or palliative therapy when prescribed combination with fluoropyrimidine-containing chemotherapy, and as induction, neoadjuvant, perioperative, or palliative when prescribed in combination with Yervoy; updated Appendix F with revised language and exception for Tennessee.
CP.PHAR.319
Ipilimumab (Yervoy)
10/01/2025
RT4: updated FDA Approved Indication(s) section and criteria to reflect revised indication that limits use to tumors expressing PD-L1 (≥ 1) for unresectable advanced or metastatic ESCC in combination with Yervoy per updated PI (previously approved regardless of PD-L1 status); also for ESCC, added option to be prescribed as palliative therapy and clarified when prescribed as induction, neoadjuvant, perioperative, or palliative therapy that tumor is characterized as MSI-H or dMMR.
CP.PHAR.367
Letermovir (Prevymis)
10/01/2025
For prophylaxis of CMV in kidney transplant recipients, added criterion limiting usage of Prevymis up to day 200 post-transplantation.
CP.PHAR.605
Adagrasib (Krazati)
10/01/2025
Per SDC for CRC, added redirection to Lumakras; for NCSLC and CRC, added step therapy bypass for IL HIM per IL HB 5395.
CP.PMN.192
Brimonidine (Mirvaso)
10/01/2025
Added redirection for brand Mirvaso requests to generic topical brimonidine.
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