New pharmacy policies
No updates this month
Revised pharmacy policies
Effective May 1, 2022
Drugs for Rare Diseases, 5.01.576
Achondroplasia (ACH)
Medical necessity
criteria updated
- Voxzogo™ (vosoritide)
-
Added specific dosing based on patient's actual body weight
Cold Agglutinin Disease
(CAD)
New policy section
Drug added
- Enjaymo™ (sutimlimab-jome)
- To decrease the need for red blood cell transfusion due to hemolysis in adults age 18 years and older with cold agglutinin disease (CAD)
Pyruvate Kinase Deficiency
(PKD)
New policy section
Drug added
- Pyrukynd® (mitapivat)
- Treatment of hemolytic anemia in adults age 18 years and older with pyruvate kinase deficiency
Folate
Antimetabolites, 5.01.617
Drug added
- Pemfexy™ (pemetrexed)
- First treatment of locally advanced or metastatic, non-squamous non-small cell lung cancer (NSCLC) when used in combination with platinum chemotherapy
- As a single agent for the maintenance treatment of locally advanced or metastatic, non-squamous NSCLC without disease progression after four cycles of platinum chemotherapy
- As a single agent for the treatment of patients with recurrent, metastatic non-squamous NSCLC who have already had chemotherapy
- First treatment of cancerous pleural mesothelioma that cannot be treated with surgery when used in combination with cisplatin
Medical
Necessity Criteria for Pharmacy Edits, 5.01.605
Anticonvulsants
Drug with new
indication
- Fintepla® (fenfluramine)
- Treatment of seizures associated with Lennox-Gastaut syndrome in patients age 2 years and older
Heart Failure Agents
Medical necessity
criteria updated
- Jardiance® (empagliflozin)
- The requirement for a reduced ejection fraction of 40% or less has been removed
Muscle Relaxants
Drug added
- Brand baclofen oral solution
mTOR Kinase Inhibitors, 5.01.533
Drug added
- Generic everolimus tablet for oral suspension
- Treatment of adults and children age 1 year and older with tuberous sclerosis complex (TSC) who have subependymal giant cell astrocytoma (SEGA)
- Treatment of adults and children age 2 years and older with TSC-associated partial-onset seizures
Medical necessity
criteria updated
- Afinitor® (everolimus tablet)
- The patient must have tried generic everolimus tablet first before the above drug can be prescribed
- Afinitor Disperz® (everolimus tablet for oral suspension)
-
The patient must have tried generic everolimus tablet
for oral suspension first before the above drug can be prescribed
Pharmacotherapy of Cushing’s Disease and Acromegaly,
5.01.548
Drug added
- Recorlev® (levoketoconazole)
- Treatment of high cortisol in patients age 18 years and older with Cushing's syndrome
Medical necessity
criteria updated
- Isturisa® (osilodrostat)
- Signifor® (pasireotide)
- Signifor® LAR (pasireotide)
- The requirement to use the drugs carbergoline and Metopirone® (metyrapone) or Lysodren® (mitotane) has been removed
- The patient must have tried generic ketoconazole before the above drugs can be prescribed
Policy statement
added
Definition of gastroenteropancreatic neuroendocrine tumor (GEP-NET)
Tadalafil Products for Benign Prostatic Hyperplasia,
5.01.545
Drug added
- Entadfi™ (finasteride and tadalafil)
- Treatment of symptoms of benign prostatic hyperplasia (BPH)
Vascular
Endothelial Growth Factor (VEGF) Receptor Inhibitors for Ocular Disorders,
5.01.620
Drug added
- Vabysmo™ (faricimab-svoa)
- Treatment of neovascular (wet) age-related macular degeneration (AMD)
- Treatment of diabetic macular edema (DME)
Medical necessity
criteria updated
- Beovu® (brolucizumab-dbll)
- Byooviz™ (ranibizumab-nuna)
- Eylea® (aflibercept)
- Lucentis® (ranibizumab)
- Macugen® (pegaptanib)
- Susvimo™ (ranibizumab)
-
Revised statement that combination treatment includes each eye treated
- Vabysmo™ (faricimab-svoa) has been added to the list of drugs that may not be used in combination treatment