New pharmacy policies
Effective May 1, 2025
Bispecific Antibodies, 5.01.650 PBC | Premera HMO
New policy
- Rybrevant (amivantamab-vmjw) moved from Epidermal Growth Factor Receptor (EGFR) Inhibitors 5.01.603 to policy 5.01.650 Bispecific Antibodies
- Columvi (glofitamab-gxbm), Epkinly (epcoritamab-bysp), Lunsumio (mosunetuzumab-axgb) moved from Monoclonal Antibodies for the Treatment of Lymphoma 2.03.502 to Bispecific Antibodies 5.01.650
- Blincyto (blinatumomab), Elrexfio (elranatamab-bcmm), Imdelltra (tarlatamab-dlle), Talvey (talquetamab-tgvs), and Tecvayli (teclistamab-cqyv) moved from Miscellaneous Oncology Drugs 5.01.540 to Bispecific Antibodies 5.01.650
- Blincyto (blinatumomab) coverage criteria to include treatment of standard or high-risk B-cell ALL in pediatric individuals
- Bizengri (zenocutuzumab-zbco) for the treatment of advanced, unresectable, or metastatic pancreatic adenocarcinoma or non-small cell lung cancer when criteria are met
- Ziihera (zanidatamab-hrii) for the treatment of biliary tract cancer when criteria are met
Revised pharmacy policies
Effective May 1, 2025
BRAF and MEK Inhibitors, 5.01.589 PBC | Premera HMO
Medical necessity criteria updated
- Braftovi (encorafenib) in combination with Erbitux (cetuximab) and mFOLFOX6 for the treatment of metastatic colorectal cancer
Drug/medical necessity criteria added
- Gomekli (mirdametinib) for the treatment of neurofibromatosis type 1 when criteria are met
Investigational criteria added
- Clarified that the medications listed in this policy are subject to the product's FDA dosage and administration prescribing information
Length of approval criteria added
- Non-formulary exception review authorizations for all drugs listed in this policy may be approved up to 12 months
Drugs for Rare Diseases, 5.01.576 PBC | Premera HMO
Medical necessity criteria updated
- Imcivree (setmelanotide) criteria age requirement changed from 6 years to 2 years of age and older
Drug/medical necessity criteria added
- Crenessity (crinecerfont) for the treatment of congenital adrenal hyperplasia when criteria are met
Immune Checkpoint Inhibitors, 5.01.591 PBC | Premera HMO
Medical necessity criteria updated
- Tevimbra (tislelizumab-jsgr) for the first-line treatment of esophageal cancer when criteria are met
Intravitreal and Suprachoroidal Corticosteroids, 5.01.619 PBC | Premera HMO
Medical necessity criteria updated
- Iluvien (fluocinolone acetonide intravitreal implant) for the treatment of chronic non-infectious uveitis affecting the posterior segment of the eye when criteria are met
Investigational criteria added
- Clarified that the medications listed in this policy are subject to the product's FDA dosage and administration prescribing information
Length of approval criteria added
- Non-formulary exception review authorizations for all drugs listed in this policy may be approved up to 12 months
Medical Necessity Criteria and Dispensing Quantity Limits for Metallic Formulary Benefits, 5.01.547 PBC | Premera HMO
Title change
- Updated the policy title from “Medical Necessity Criteria and Dispensing Quantity Limits for Exchange Formulary Benefits” to “Medical Necessity Criteria and Dispensing Quantity Limits for Metallic Formulary Benefits.”
Section removed
- ‘Step Therapy Protocol’ and ‘Drugs Subject to the Step Therapy Protocol’ removed
Medical Necessity Criteria for Pharmacy Edits, 5.01.605 PBC | Premera HMO
Drug/medical necessity criteria added
- Zunveyl (benzgalantamine) for the treatment of mild to moderate dementia of Alzheimer’s disease when criteria are met
- Flagyl (metronidazole) and Likmez (metronidazole) added to Antibiotics
- Venxxiva (tiopronin delayed-release) added to Cystine Binding Drugs
- Brand metaxalone added to Muscle Relaxants
- PR benzoyl peroxide 7% wash and MetroLotion (metronidazole lotion) added to Brand Topical Acne or Rosacea Agents
- Rocaltrol (calcitriol) oral solution added to Vitamin Agents
- Azmiro (testosterone cypionate) added to Testosterone Replacement Products
Drug/medical necessity criteria removed
- Evekeo ODT removed from brand ADHD Drugs as the product has been discontinued
- Dexonto (dexamethasone) removed from Brand Topical Corticosteroids
Migraine and Cluster Headache Medications, 5.01.503 PBC | Premera HMO
Medical necessity criteria updated
- Corrected policy language for drugs with additional quantities from “at least 30 doses per 30 days” to “less than 30 doses per 30 days”
Drug/medical necessity criteria updated
- Symbravo (rizatriptan/meloxicam) for the acute treatment of migraine headaches when criteria are met
Miscellaneous Oncology Drugs, 5.01.540 PBC | Premera HMO
Medical necessity criteria updated
- Tabloid (thioguanine) criteria updated to include treatment of acute lymphoblastic leukemia
- Dacogen (decitabine) and generic decitabine coverage criteria to include treatment of acute myeloid leukemia
Drug/medical necessity criteria added
- Revuforj (revumenib) for the treatment of acute leukemia when criteria are met
- Romvimza (vimseltinib) for the treatment of tenosynovial giant cell tumor when criteria are met
- Beizray (docetaxel) for the treatment of various cancers, including breast cancer, non-small cell lung cancer, prostate cancer, gastric adenocarcinoma, and squamous cell carcinoma of the head and neck when criteria are met
Monoclonal Antibodies for the Treatment of Lymphoma, 2.03.502 PBC | Premera HMO
Medical necessity criteria updated
- Polivy (polatuzumab vedotin-piiq) criteria to include use as bridging therapy prior to a planned CD-19 CAR-T treatment when criteria are met
Pharmacologic Treatment of Cystic Fibrosis, 5.01.539 PBC | Premera HMO
Title change
- Policy title changed from “Pharmacologic Treatment of Cystic Fibrosis with Ivacaftor Products” to “Pharmacologic Treatment of Cystic Fibrosis.”
Drug/medical necessity criteria added
- Alyftrek (vanzacaftor/tezacaftor/ deutivacaftor) for the treatment of cystic fibrosis (CF) when criteria are met
Medical necessity criteria updated
- Clarified that the following drugs cannot be used in combination: Alyftrek (vanzacaftor/tezacaftor/ deutivacaftor), Kalydeco (ivacaftor), Orkambi (lumacaftor/ivacaftor), Symdeko (tezacaftor/ivacaftor), and Trikafta (elexacaftor/tezacaftor/ivacaftor)
- Trikafta (elexacaftor/ tezacaftor/ivacaftor) for the treatment of CF who have a mutation that is responsive to Trikafta based on clinical and/or in vitro data when criteria are met
- Quantity limits added per the prescribing information for Kalydeco (ivacaftor), Orkambi (lumacaftor/ivacaftor), Symdeko (tezacaftor/ivacaftor), and Trikafta (elexacaftor/tezacaftor/ivacaftor)
Investigational criteria added
- Clarified that the medications listed in this policy are subject to the product's FDA dosage and administration prescribing information
Length of approval criteria added
- Non-formulary exception review authorizations for all drugs listed in this policy may be approved up to 12 months
Pharmacologic Treatment of Hemophilia, 5.01.581 PBC | Premera HMO
Drug/medical necessity criteria added
- Alhemo (concizumab-mtci) for the treatment of hemophilia A and hemophilia B when criteria are met
- Qfitlia (fitusiran) for the treatment of hemophilia A and hemophilia B when criteria are met
Medical necessity criteria removed
- Beqvez (fidanacogene elaparvovec-dzkt) removed from policy as the product has been discontinued
Pharmacologic Treatment of High Cholesterol, 5.01.558 PBC | Premera HMO
Pharmacologic Treatment of Psoriasis, 5.01.629 PBC | Premera HMO
Length of approval criteria updated
- Re-authorization duration of approval changed from 3 years to 12 months
Pharmacologic Treatment of Sickle Cell Disease, 5.01.640 PBC | Premera HMO
Drug/medical necessity criteria added
- Xromi (hydroxyurea) to reduce the frequency of painful crises and reduce the need for blood transfusions in individuals with sickle cell anemia with recurrent moderate to severe painful crises when criteria are met
Pharmacotherapy of Arthropathies, 5.01.550 PBC | Premera HMO
Medical necessity criteria updated
- Adalimumab products, Enbrel (etanercept), Simponi Aria (golimumab), tocilizumab products, Kevzara (sarilumab), Orencia (abatacept), and Cimzia (certolizumab pegol) polyarticular juvenile idiopathic arthritis (PJIA) criteria updated to require that
the individual has aggressive disease
- Tocilizumab products PJIA and rheumatoid arthritis criteria updated to add an exception to the brand step therapy requirement if the individual has heart failure or a previously treated lymphoproliferative disorder
- Kevzara (sarilumab) rheumatoid arthritis criteria updated to add an exception to the brand step therapy requirement if the individual has heart failure or a previously treated lymphoproliferative disorder
- Orencia (abatacept) psoriatic arthritis, rheumatoid arthritis, and PJIA criteria updated to add an exception to the brand step therapy requirement if the individual has heart failure, a previously treated lymphoproliferative disorder, a previous serious
infection, or a demyelinating disorder
- Kevzara (sarilumab) PJIA criteria updated to add an exception to the brand step therapy requirement if the individual has heart failure, a previously treated lymphoproliferative disorder, a previous serious infection, or a demyelinating disorder
Length of approval criteria updated
- Re-authorization duration of approval changed from 3 years to 12 months
Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563 PBC | Premera HMO
Drugs/medical necessity criteria added
- Omvoh (mirikizumab-mrkz) IV/SC and Tremfya (guselkumab) IV/SC for the treatment of moderately to severely active Crohn’s disease when criteria are met
Length of approval criteria updated
- Re-authorization duration of approval changed from 3 years to 12 months
SGLT2 Inhibitors, 5.01.646 PBC | Premera HMO
New formatting
- Section 1 includes coverage criteria for Incentive, Open, and Select formulary plans (Rx Plan A1, A2, B3, B4, C4, F1, and G3) and plans with no pharmacy benefit coverage
- Section 2 includes separate coverage criteria for Essentials Formulary (Rx plan E1, E3, E4, M1, M2, and M4) plans
- Section 3 includes separate coverage criteria for the Metallic (individual/small group/student ISHIP) plans
Length of approval criteria updated
- Re-authorization duration of approval changed from 3 years to 12 months