New pharmacy policies
Effective May 1, 2023
No updates this month
Revised pharmacy policies
Effective May 1, 2023
Amyloid Antibodies for the Treatment of Alzheimer’s Disease, 5.01.626 PBC | Premera HMO
Drug added
Leqembi™ (lecanemab-irmb)
- Considered investigational for all indications, including for treatment of Alzheimer’s disease
Botulinum Toxins, 5.01.512 PBC | Premera HMO
Drug added
Daxxify® (daxibotulinumtoxinA-lanm)
- Considered cosmetic for treatment of wrinkles and not covered
- Considered investigational for all other indications
Medical necessity criteria updated
Added coverage for adults with hemifacial spasms
- Botox® (onabotulinumtoxinA)
- Dysport® (abobotulinumtoxinA)
- Myobloc® (rimabotulinumtoxinB)
- Xeomin® (incobotulinumtoxinA)
Investigational criteria updated
Added exception as noted in medical necessity section for prevention of chronic migraine headache
- Botox® (onabotulinumtoxinA)
Drugs for Rare Diseases, 5.01.576 PBC | Premera HMO
Alpha-mannosidosis
Drug added
Lamzede ® (velmanase alfa) IV
- Added criteria for treatment of non-central nervous system manifestations for the initial approval of 1 year
Friedreich’s ataxia
Drug added
Skyclarys TM (omaveloxolone) oral
- Added criteria for individuals aged 16 years or older for the initial approval of 1 year
Rett syndrome
Drug added
DaybueTM (trofinetide) oral solution
- Added criteria for individuals aged 2 years or older for the initial approval of 3 months
Alagille syndrome (ALGS)
Medical necessity criteria updated
Expanded criteria to include individuals 3 months of age or older when treating pruritus
- Livmarli™ (maralixibat) oral
Primary hyperoxaluria type 1
Medical necessity criteria updated
Added criteria to include lowering of plasma oxalate levels in pediatric and adult individuals
Thyroid disease
Medical necessity criteria updated
Removed the criterion “with expertise in TED treatment” within the prescriber requirements
- Tepezza™ (teprotumumab-trbw) IV
Folate Antimetabolites, 5.01.617 PBC | Premera HMO
Drug added
Jylamvo® (methotrexate) oral solution
- Added medical necessity criteria for individuals who have tried and failed generic methotrexate tablets
Medical necessity criteria updated
Added additional criterion for combination therapy with Keytruda® and platinum chemotherapy for initial treatment of metastatic non-squamous non-small lung cell cancer
Gonadotropin Releasing Hormone (GnRH) Analogs, 5.01.625 PBC | Premera HMO
Drugs added
Brand leuprolide depot
- Added medical necessity criteria for treatment of endometriosis, prostate cancer, and uterine fibroids
Gender dysphoria
Added medical necessity criteria, including criterion for documentation of discussion about adverse side effects
- Brand leuprolide depot
- Zoladex® (goserelin)
Ovulation suppression
Generic leuprolide
- Added indication for treatment of ovulation suppression for purposes of a frozen embryo transfer (FET)
Investigational criteria updated
Clarified that all other drugs for treatment of gender dysphoria not explicitly listed in the policy are considered investigational
Hemlibra® (emicizumab-kxwh), 5.01.581 PBC | Premera HMO
Policy title changed
From Hemlibra® (emicizumab-kxwh) to Pharmacologic Treatment of Hemophilia
Drug added
Hemgenix® (etranacogene dezaparvovec-drlb)
- For treatment of severe or moderately severe hemophilia B in adult individuals 18 years or older who were assigned male at birth
- Considered investigational for other conditions not outlined in the policy and for repeat treatment
Miscellaneous Oncology Drugs, 5.01.540 PBC | Premera HMO
Oral Drugs
Medical necessity criteria updated
Indication clarified as applicable to maintenance treatment of adult individuals with deleterious or suspected deleterious germline BRCA-mutated recurrent cancers as listed in the policy
Removed requirement of Ki-67 score of 20 or greater when used in combination with endocrine therapy for the adjuvant treatment of adult individuals with HR-positive, HER2-negative, node-positive early breast cancer at elevated risk of recurrence
- Verzenio™ (abemaciclib) oral
Medical Necessity Criteria for Pharmacy Edits, 5.01.605 PBC | Premera HMO
Drug added
Antifungals
Emverm® (mebendazole)
- For treatment of hookworm, roundworm, tapeworm, whipworm
- For treatment of pinworm when an individual has a history of intolerance to over-the-counter pyrantel pamoate
- Initial approval is for 3 months
Drug added
Brand Intranasal Histamine Products
Patanase®
- For treatment of allergic rhinitis when the individual has tried and failed at least two generic intranasal corticosteroids or antihistamine products
Drugs added
Brand Ophthalmic Corticosteroids
Indicated when trial and failure of generic
- TobraDex (tobramycin-dexamethasone)
- Tobramycin-dexamethasone
Drugs added
Brand Second Generation Antipsychotics
- Abilify® (aripiprazole)
- Brand clozapine ODT
- Geodon® (ziprasidone)
- Invega® (paliperidone)
- Risperdal® (risperidone)
- Seroquel® (quetiapine)
- Vraylar® (cariprazine)
- Zyprexa® (olanzapine)
- Zyprexa® Zydis (olanzapine)
Drug added
Chelating Agents
Chemet® (succimer)
- For treatment of acute lead poisoning in individuals aged 12 months to 18 years
- For treatment of acute intoxication or poisoning by arsenic or mercury
Drugs added
Parkinson’s Disease Agents
For treatment of Parkinson’s disease when the individual has tried and failed or is intolerant to other therapies
- Dhivy™ (carbidopa-levodopa)
- Duopa® (carbidopa-levodopa)
- Lodosyn® (carbidopa)
- Rytary® (carbidopa-levodopa)
- Sinemet® (carbidopa-levodopa)
- Stalevo (carbidopa-levodopa-entacapone)
- Xadago (safinamide)
Drug added
Tardive Dyskinesia & Huntington’s Disease Medications
Austedo XR (deutetrabenazine extended release)
- For treatment of DRBA (dopamine receptor blocking agents)-induced tardive dyskinesia or chorea associated with Huntington’s disease
Drug added
Wound Therapy
Nexobrid® (anacaulase-bcdb)
- For treatment of deep partial thickness or full thickness thermal burns in those aged 18 years or older
Medical necessity criteria updated
Antipsychotics, Second Generation
Requires trial and failure with generic lurasidone
Heart Failure Agents
Requires previous therapy with the maximum tolerated dose of a beta blocker for adults. Added a prescriber requirement to adult and pediatric criteria.
Requires an eGFR of 25 mL/min/1.73m2 or greater to initiate therapy
Requires an eGFR of 20 mL/min/1.73m2 or greater to initiate therapy
- Jardiance® (empagliflozin)
Nulojix® (belatacept) for Adults, 5.01.536 PBC | Premera HMO
Prophylaxis of organ rejection in adult individuals receiving a kidney transplant
Medical necessity criteria updated
- Clarified that when used for induction or maintenance therapy, requires combination with all listed agents
- Azathioprine can be used for individuals who have tried and did not tolerate mycophenolate mofetil (MMF) as a regimen for immunosuppressive post-induction or post-transplant therapy
Pharmacologic Treatment of Atopic Dermatitis, 5.01.628 PBC | Premera HMO
Janus Kinase (JAK) Inhibitors
Medical necessity criteria updated
Updated age limit from 18 years and older to 12 years and older
- Cibinqo™ (abrpcotomob) oral
Cosmetic criteria updated
For treatment of vitiligo is cosmetic and not covered
- Opzelura™ (ruxolitinib) topical cream
Pharmacotherapy of Type I and Type II Diabetes Mellitus, 5.01.569 PBC | Premera HMO
Long–Acting Insulin
Drugs added
Added as non-preferred long-acting insulin agents
- Insulin Degludec (degludec)
- Rezvoglar™ (glargine-aglr)
Authorization Updated
Updated initial and re-authorization duration for all drugs listed in the policy for up to 3 years, with the exception of Tzield
Spravato® (esketamine) Nasal Spray, 5.01.609 PBC | Premera HMO
Medical necessity criteria updated
- Clarified documentation of major depressive disorder without psychotic features (unipolar, not bipolar)
- Clarified requirement of no current substance use disorder unless in remission or confined 24/7 in a facility with no access to substances
- Clarified requirement of no concurrent use of any of the specified drugs in excess of prescribed doses
- Clarified requirement of no alcohol or marijuana use within 24 hours before and after each treatment
- Added additional information on major depressive disorder
- Clarified that continued approval must meet medical necessity criteria
Documentation requirements updated
Added requirement that the oral antidepressant used concomitantly must be specifically named
Xolair® (omalizumab), 5.01.513 PBC | Premera HMO
Moderate to severe persistent asthma
Medical necessity criteria updated
Updated definition of moderate to severe persistent asthma to include individuals with one or more asthma exacerbations in the previous 12 months requiring use of oral corticosteroids