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Medical Policy Number
| Medical Policy Name | Effective Date of Change | Description of Changes |
|---|
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AR.QC.PMN.214 |
Continuous Glucose Monitors
|
03/01/2026 |
2026 annual review: per SDC, removed age requirement for initial approval. |
|
CP.PCH.28 |
Diclofenac (Cambia, FlectPO, Licart, Pennsaid, Solaraze, ZipsPO, ZPOvolex)
|
03/01/2026 |
4Q 2025 annual review: added step therapy bypass for IL HIM per IL HB 5395; added must use generic formulation language for brand Flector, Licart, Zipsor and Pennsaid in continued therapy; added must use generic formulation language for Cambia requests; references reviewed and updated. |
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CP.PCH.53 |
Leuprolide Acetate (Lupron, Eligard, Lupaneta Pack, Fensolvi, Camcevi)
|
03/01/2026 |
4Q 2025 annual review: per NCCN for ovarian cancer added supported uses in malignant sex cord-stromal tumors, carcinosarcoma (malignant mixed Müllerian tumors), low-grade serous carcinoma, endometrioid carcinoma, mucinous neoplasms of the ovary; added Eligard as a product that can be used for breast cancer; added Camcevi as a product that can be used for salivary gland tumors; added criteria set for uterine sarcoma; for endometriosis and uterine leiomyomata (fibroids), added allowance for age < 18 years when member is postpubertal per prescribing information; added step therapy bypass for IL HIM per IL HB 5395; RT4: added new strength, Camcevi ETM (21 mg); references reviewed and updated. |
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CP.PCH.57 |
Abrocitinib (Cibinqo)
|
03/01/2026 |
Policy created per August SDC (adapted from CP.PHAR.578 with the following revisions: for atopic dermatitis initial approval criteria, added redirection to preferred agents Dupixent and Rinvoq.) |
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CP.PCH.58 |
Lebrikizumab (Ebglyss)
|
03/01/2026 |
Policy created per August SDC (adapted from CP.PHAR.704 with the following revisions: for atopic dermatitis initial approval criteria, added redirection to preferred agents Dupixent or Rinvoq). |
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CP.PCH.59 |
Nemolizumab-ilto (Nemluvio) |
03/01/2026 |
Policy created per August SDC (adapted from CP.PHAR.703 with the following revisions: for atopic dermatitis initial approval criteria, added redirection to preferred agents Dupixent or Rinvoq). |
|
CP.PCH.60 |
Tralokinumab-ldrm (Adbry) |
03/01/2026 |
Policy created per August SDC (adapted from CP.PHAR.577 with the following revisions: for atopic dermatitis initial approval criteria, added redirection to preferred agents Dupixent or Rinvoq). |
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CP.PHAR.130 |
Avatrombopag (Doptelet) |
03/01/2026 |
4Q 2025 annual review: RT4: updated pediatric extension for ITP and added new formulation Doptelet Sprinkle (oral granules) to policy; for ITP diagnosis criterion, added option that ITP could be persistent; approval duration for ITP revised from 6 months to 12 months; references reviewed and updated. |
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CP.PHAR.246 |
Canakinumab (Ilaris) |
03/01/2026 |
For sJIA, added bypass of conventional therapies if a member has failed a biologic agent to clarify intention of not stepping back from biologic agent to conventional therapy.
Extended initial approval durations to 12 months for chronic conditions. |
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CP.PHAR.259 |
Natalizumab (Tysabri, Tyruko) |
03/01/2026 |
For CD, added bypass of conventional therapies if a member has failed a biologic agent to clarify intention of not stepping back from biologic agent to conventional therapy.
Extended initial approval durations to 12 months for CD. |
|
CP.PHAR.260 |
Rituximab (Rituxan, Riabni, Ruxience, Truxima, Rituxan Hycela) |
03/01/2026 |
Per SDC, added off-label criteria for bullous pemphigoid; for RA, added bypass of conventional therapies if a member has failed a biologic agent to clarify intention of not stepping back from biologic agent to conventional therapy; removed Castleman Disease from B-cell lymphoma initial approval criteria as Castleman Disease is not categorized as B-cell lymphoma per NCCN and added Castleman Disease to NCCN Compendium Indications (off-label) initial approval criteria.
Extended initial approval durations to 12 months for chronic conditions. |
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CP.PHAR.317 |
Cetuximab (Erbitux) |
03/01/2026 |
4Q 2025 annual review: per NCCN – for HNSCC, added option for use if member is receiving reirradiation with concurrent radiotherapy; for CRC, replaced “unresectable” with “recurrent”, specified that POLE/POLD1 mutation positive disease must have ultra-hypermutated phenotype, removed prior therapy requirement when prescribed for BRAF V600E mutation positive in combination with Braftovi and added clarification that regimen may be “with or without FOLFOX”, and modified requirement for left-sided colon cancer to also apply to unresectable metachronous metastases; for NSCLC, simplified criterion requiring disease progression on prior therapy to no longer call out T790M positive disease; extended initial approval duration for HIM/Medicaid from 6 to 12 months; revised approval durations for Commercial from 6/12 months to standard injectable authorization of “6 months or to the member’s renewal date, whichever is longer”; references reviewed and updated. |
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CP.PHAR.321 |
Panitumumab (Vectibix) |
03/01/2026 |
4Q 2025 annual review: specified that POLE/POLD1 mutation positive disease must have ultra-hypermutated phenotype and specified that unresectable synchronous metastases are in the liver and/or lung per NCCN; extended initial approval duration for HIM/Medicaid from 6 to 12 months; revised approval durations for Commercial from 6/12 months to standard injectable authorization of “6 months or to the member’s renewal date, whichever is longer”; references reviewed and updated. |
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CP.PHAR.367 |
Letermovir (Prevymis) |
02/01/2026 |
Added criterion Prevymis must be initiated within 7 days post kidney transplant and 28 days post HSCT per PI. |
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CP.PHAR.397 |
Cemiplimab-rwlc (Libtayo) |
03/01/2026 |
4Q 2025 annual review: for CSCC, added option for disease that is satellitosis/in-transit metastasis that is unresectable or incompletely resected per NCCN; for cervical, vaginal cancer and vulvar cancer, clarified usage as second-line or subsequent therapy per NCCN; added off-label indications for anal carcinoma and dMMR/MSI-H or POLE/POLD1 mutation with tumor cancers for: small bowel adenocarcinoma, and rectal and colon cancer per NCCN; initial approval durations changed from 6 to 12 months for Medicaid/HIM; references reviewed and updated.
RT4: added new indication for adjuvant treatment of adult patients with CSCC at high risk of recurrence after surgery or curative radiation; added disease qualifiers for neoadjuvant use per NCCN. |
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CP.PHAR.400 |
Duvelisib (Copiktra) |
03/01/2026 |
4Q 2025 annual review: fPO all indications, extended initial approval duration fPO Medicaid and HIM from 6 months to 12 months fPO this maintenance medication fPO a chronic condition; fPO off-label T-cell lymphomas, added option fPO use in combination with romidepsin per NCCN; references reviewed and updated. |
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CP.PHAR.58 |
Denosumab (Prolia, Xgeva and biosimilars) |
03/01/2026 |
Per August SDC: for multiple myeloma or solid tumor, giant cell tumor of bone, hypercalcemia of malignancy, systemic mastocytosis, added redirection to Osenvelt and Wyost if request is for a product other than Osenvelt and Wyost for initial and continuation of therapy requests.
RT4: added new biosimilars Bildyos and Bilprevda to criteria. Added new HCPCS codes Q5157, Q5158, Q5159. Added step therapy bypass for IL HIM per IL HB 5395.
RT4: added new biosimilars Bosaya, Aukelso, Enoby, and Xtrenbo to criteria |
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CP.PHAR.730 |
Zopapogene Imadenovec (Papzimeos) |
03/01/2026 |
RT1: drug is now FDA-approved; added option to be prescribed by or in consultation with a pulmonologist; for HPV vaccination requirement, clarified the vaccination series must be completed; references reviewed and updated. |
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CP.PMN.266 |
Finerenone (Kerendia) |
03/01/2026 |
4Q 2025 annual review: RT4: added new heart failure indication and accompanying 40 mg dosage strength; fPO CKD, added criterion requiring serum potassium ≤ 5.0 mEq/L per PI; references reviewed and updated. |
|
HIM.PA.03 |
Ophthalmic Corticosteroids |
03/01/2026 |
4Q 2025 annual review: added step therapy bypass for IL HIM per IL HB 5395; removed FML suspension as it is discontinued; clarified ≥ 18 age requirement applies to Lotemax suspension and ointment per PI; references reviewed and updated. |
|
HIM.PA.147 |
Doxepin (Silenor, Prudoxin, Zonalon) |
03/01/2026 |
4Q 2025 annual review: added step therapy bypass for IL HIM per IL HB 5395; for insomnia, extended initial approval duration from 6 to 12 months; for pruritis, added existing quantity limit (1 tube per 6 months) directly into criteria; references reviewed and updated. |
|
HIM.PA.17 |
Methoxsalen (Uvadex) |
03/01/2026 |
4Q 2025 annual review: per NCCN, added Lymphir as an alternative prior therapy option; revised step therapy to require lack of response to other forms of therapy for IL HIM per IL HB 5395; revised initial approval duration from 7 to up to 20 cycles to reflect the maximum number of cycles allowed per FDA labeling; references reviewed and updated. |
|
HIM.PA.173 |
Palbociclib (Ibrance) |
03/01/2026 |
4Q 2025 annual review: for soft tissue sarcoma, removed “retroperitoneal” and added criteria “request is for capsule formulation” per NCCN; for initial approval criteria, extended approval duration from 6 months to 12 months; references reviewed and updated. |
|
HIM.PA.175 |
Mepolizumab (Nucala) |
01/01/2026 |
Revised initial approval durations from 6 to 12 months. Per SDC request, the following revisions were made: for asthma increased required exacerbations from 1 to 2 in the last 12 months, added redirection to Dupixent and Fasenra; for EGPA added redirection to Fasenra; for HES added redirection to corticosteroid and removed criteria requiring member has tried at least one other HES treatment for a minimum of 4 weeks; for CRSwNP increased required intranasal corticosteroids from 1 to 2, added redirection to Dupixent for initial and continuation requests; for COPD added redirection to Dupixent. |
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HIM.PA.176 |
Tezepelumab (Tezspire) |
03/01/2026 |
Removed continued therapy redirection to Dupixent, Fasenra, and Nucala; added step therapy bypass for IL HIM per IL HB 5395. |
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HIM.PA.SP60 |
Biologic and Non-biologic DMARDs |
03/01/2026 |
RT4: for Otezla, added newly approved pediatric extension to 6 years and older for PsA and applied redirection to Otezla for pediatric agents indicated for PsA; RT4: for Avtozma, added newly approved CRS indication to criteria; for UC, added option for Mayo Endoscopic Score > 2 to define moderate-to-severe UC; added bypass of conventional therapies if a member has failed a biologic agent to clarify intention of not stepping back from biologic agent to conventional therapy; RT4: for Skyrizi, added new 180 mg/1.2 mL single-dose prefilled syringe dosage form and strength; for Skyrizi CD and UC criteria, added “if request is for vials/cartridges” to clarify quantity limit applies to vial/cartridge requests only; added HCPCS code [Q5156] for Avtozma.
RT4: for Tremfya, added newly approved pediatric age extension to 6 years and older for PsO and PsA and updated UC induction dosing per PI.
RT4: for Rinvoq, reflected place in therapy for UC and CD per PI.
RT4: for Simponi, reflected pediatric age extension for UC per PI.
Extended initial approval durations to 12 months for chronic conditions.
RT4: for Xeljanz, applied pediatric age extension for PsA per PI.
RT4: for Amjevita, Cyltezo, Hyrimoz, Simlandi, and Yuflyma, applied pediatric age extensions for HS and UV per PI.
RT4: added newly FDA-approved formulation, Otezla XR. |
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QR.QC.CP.352 |
Semaglutide (Wegovy) |
03/01/2026 |
Added preferred product Mounjaro to list of required T&F. |
