For MDS, revised criterion MDS with ring sideroblasts < 15% (or ring sideroblasts 500 mU/mL” to “one of the following: response to or ineligible for ESA therapy OR both of the following: documentation of current serum erythropoietin < 500 mU/mL AND failure of Retacrit or if Retacrit is unavailable due to shortage, member must use Epogen” to direct to our preferred ESA agents; for MDS initial approval criteria, added “MDS that is very low, low, or intermediate-1 risk as classified by IPSS-R” as an option under diagnosis; for MDS initial and continued therapy criteria, added “Reblozyl is not prescribed concurrently with Rytelo”.
CP.PHAR.612
Tremelimumab-actl (imjudo)
12/01/24
For uHCC, revised continued therapy section to not permit re-authorization per package insert.
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