New pharmacy policies
Effective August 1, 2023
No updates this month
Revised pharmacy policies
Effective August 1, 2023
BCR-ABL Kinase Inhibitors, 5.01.518 PBC | Premera HMO
Medical necessity criteria updated
- Gleevec (imatinib)
- Updated criteria to have trial and failure to generic imatinib
- Removed refractory and relapsed, and added in combination with chemotherapy to the criteria for treatment of adult and pediatric individuals with Philadelphia Chromosome positive acute lymphoblastic leukemia
- Sprycel (dasatinib)
- Updated criteria to include treatment of newly diagnosed pediatric and adult individuals with Philadelphia Chromosome positive acute lymphoblastic leukemia in combination with chemotherapy
Medical necessity criteria added
- Generic imatinib
- Added a new coverage criterion for generic imatinib
Medical Necessity Criteria for Pharmacy Edits, 5.01.605 PBC | Premera HMO
Attention-deficit/hyperactivity disorder drugs, brands
Drug added
- Xelstrym (dextroampetamine)
Constipation
Drug added
- Linzess (linaclotide)
- Treatment of functional constipation in pediatric individuals 6 to 17 years old
Dry Eye
Drug added
- Vevye (cyclosporin Ophthalmic solution)
- Treatment of dry eye disease
Monoclonal Antibodies for the Treatment of Lymphoma, 2.03.502 PBC | Premera HMO
Medical necessity criteria added
- Columvi (glofitamab-gxbm)
- Treatment of adult individuals with relapsed or refractory diffuse large B-cell lymphoma, not otherwise specified or large B-cell lymphoma arising from follicular lymphoma, after two or more lines of systemic therapies
Multiple Receptor Tyrosine Kinase Inhibitors, 5.01.534 PBC | Premera HMO
Medical necessity criteria updated
- Ayvakit (avapritinib)
- Updated indication to include treatment of adult individuals with indolent systemic mastocytosis
Pharmacologic Treatment of Clostridioides Difficile, 5.01.631 PBC | Premera HMO
Drug added
- Vowst (fecal microbiota spores, live-brbk)
Pharmacologic Treatment of Psoriasis, 5.01.629 PBC | Premera HMO
Second-Line IL-17 Inhibitors
Drugs added
- Cyltezo LCF (adalimumab-adbm) OR HyrimozTM HCF (adalimumab-adaz) OR Adalimumab-adaz HCF (Sandoz – unbranded)
- Added to the list of drugs that must be tried and failed to qualify for Siliq (brodalumab) for treatment of moderate to severe plaque psoriasis
- Added to the list of drugs that must be tried and failed to qualify for Cosentyx (secukinumab) SC for treatment of moderate to severe plaque psoriasis
Second-Line IL-23 Inhibitors
Drugs added
- Cyltezo LCF (adalimumab-adbm) OR HyrimozTM HCF (adalimumab-adaz) OR Adalimumab-adaz HCF (Sandoz – unbranded)
- Added to the list of drugs that must be tried and failed to qualify for Ilumya (tildrakizumab-asmn) for treatment of moderate to severe plaque psoriasis
Second-Line Tyrosine Kinase 2 (TYK2) Inhibitors
Drugs added
- Cyltezo LCF (adalimumab-adbm) OR HyrimozTM HCF (adalimumab-adaz) OR Adalimumab-adaz HCF (Sandoz – unbranded)
- Added to the list of drugs that must be tried and failed to qualify for Sotyktu (deucravacitinib) for treatment of moderate to severe plaque psoriasis
TNF-α Inhibitors
Drugs added
- Cyltezo LCF (adalimumab-adbm), Hyrimoz HCF (adalimumab-adaz) and Adalimumab-adaz HCF (Sandoz – unbranded) SC
- Treatment of plaque psoriasis as preferred products and with the identical coverage criteria as Amjevita (adalimumab-atto) [NDCs starting with 55513]
Second-Line TNF-α Inhibitors
Drugs added
- Hyrimoz LCF (adalimumab-adaz) SC, Abrilada (adalimumab-afzb) SC, Hulio (adalimumab-fkjp) SC, Yusimry (adalimumab-aqvh) SC, Hadlima (adalimumab-bwwd) SC and Yuflyma (adalimumab-aaty) SC
- Treatment of plaque psoriasis as non-preferred products and with the identical coverage criteria as Amjevita (adalimumab-atto) [NDCs starting with 72511]
Pharmacotherapy of Arthropathies, 5.01.550 PBC | Premera HMO
Second Line TNF-α Antagonists
Medical necessity criteria removed
- Individual is being started on Amjevita (adalimumab-atto) [NDCs starting with 72511], Humira (adalimumab), or Enbrel (etanercept) concurrently with leflunomide, methotrexate, or sulfasalazine
- Removed from non-preferred agents’ indication of treatment of polyarticular juvenile idiopathic arthritis
First-Line TNF-α Inhibitors
Drugs added
- Cyltezo LCF(adalimumab-adbm), Hyrimoz HCF (adalimumab-adaz) and Adalimumab-adaz HCF (Sandoz – unbranded) SC
- Treatment of ankylosing spondylitis, rheumatoid arthritis, polyarticular juvenile idiopathic arthritis, and psoriatic arthritis as preferred products and with the identical coverage criteria as Amjevita (adalimumab-atto) [NDCs starting with 55513]
Second-Line TNF-α Inhibitors
Drugs added
- Hyrimoz LCF (adalimumab-adaz) SC, Abrilada (adalimumab-afzb) SC, Hulio (adalimumab-fkjp) SC, Yusimry (adalimumab-aqvh) SC, Hadlima (adalimumab-bwwd) SC and Yuflyma (adalimumab-aaty) SC
- Treatment of ankylosing spondylitis, rheumatoid arthritis, polyarticular juvenile idiopathic arthritis, and psoriatic arthritis as non-preferred products and with the identical coverage criteria as Amjevita (adalimumab-atto) [NDCs starting with 72511]
- Cyltezo LCF (adalimumab-adbm) OR HyrimozTM HCF (adalimumab-adaz) OR Adalimumab-adaz HCF (Sandoz – unbranded)
- Added to the list of drugs that must be tried and failed to qualify for Simponi Aria (golimumab) for treatment of polyarticular juvenile idiopathic arthritis
Second-Line IL-1 Inhibitors
Drugs added
- Cyltezo LCF (adalimumab-adbm) OR HyrimozTM HCF (adalimumab-adaz) OR Adalimumab-adaz HCF (Sandoz – unbranded)
- Added to the list of drugs that must be tried and failed to qualify for Kevzara (sarilumab) SC for treatment of severe rheumatoid arthritis
First-Line IL-6 Inhibitors
Drugs added
- Cyltezo LCF (adalimumab-adbm) OR HyrimozTM HCF (adalimumab-adaz) OR Adalimumab-adaz HCF (Sandoz – unbranded)
- Added to the list of drugs that must be tried and failed to qualify for Actemra (tocilizumab) for treatment of polyarticular juvenile idiopathic arthritis, and severe rheumatoid arthritis
Second-Line IL-17 Inhibitors
Drugs added
- Cyltezo LCF (adalimumab-adbm) OR HyrimozTM HCF (adalimumab-adaz) OR Adalimumab-adaz HCF (Sandoz – unbranded)
- Added to the list of drugs that must be tried and failed to qualify for Cosentyx (secukimumab) SC for treatment of ankylosing spondylitis, and active psoriatic arthritis
Second-Line Janus Kinase Inhibitors
Drugs added
- Cyltezo LCF (adalimumab-adbm) OR HyrimozTM HCF (adalimumab-adaz) OR Adalimumab-adaz HCF (Sandoz – unbranded)
- Added to the list of drugs that must be tried and failed to qualify for Olumiant (baricitinib) oral for treatment of severe rheumatoid arthritis
Second-Line T-Cell Costimulation Modulators
Drugs added
- Cyltezo LCF (adalimumab-adbm) OR HyrimozTM HCF (adalimumab-adaz) OR Adalimumab-adaz HCF (Sandoz – unbranded)
- Added to the list of drugs that must be tried and failed to qualify for Orencia (abatacept) IV/SC for treatment of polyarticular juvenile idiopathic arthritis, and severe rheumatoid arthritis, and active psoriatic arthritis
Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563 PBC | Premera HMO
First-Line TNF-α Inhibitors
Drugs added
- Cyltezo LCF (adalimumab-adbm), Hyrimoz HCF (adalimumab-adaz) and Adalimumab-adaz HCF (Sandoz – unbranded) SC
- Treatment of Crohn’s disease and ulcerative colitis as preferred products and with the identical coverage criteria as Amjevita (adalimumab-atto) [NDCs starting with 55513]
Second Line TNF-α Inhibitors
Drugs added
- Hyrimoz LCF (adalimumab-adaz) SC, Abrilada (adalimumab-afzb) SC, Hulio (adalimumab-fkjp) SC, Yusimry (adalimumab-aqvh) SC, Hadlima (adalimumab-bwwd) SC and Yuflyma (adalimumab-aaty) SC
- Treatment of Crohn’s disease and ulcerative colitis as non-preferred products and with the identical coverage criteria as Amjevita (adalimumab-atto) [NDCs starting with 72511]
Second-line Sphingosine 1-Phosphate Receptor Modulators
- Cyltezo LCF (adalimumab-adbm), Hyrimoz HCF (adalimumab-adaz) and Adalimumab-adaz HCF (Sandoz – unbranded) SC
- Added to the list of drugs that must be tried and failed to qualify for Zeposia (ozanimod) oral for treatment of ulcerative colitis
Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564 PBC | Premera HMO
TNF-α Inhibitors
Drugs added
- Cyltezo LCF (adalimumab-adbm), Hyrimoz HCF (adalimumab-adaz) and Adalimumab-adaz HCF (Sandoz – unbranded) SC
- Treatment of hidradenitis suppurativa, pyoderma gangrenosum, and uveitis as preferred products and with the identical coverage criteria as Amjevita (adalimumab-atto) [NDCs starting with 55513]
Second Line TNF-α Inhibitors
Drugs added
- Hyrimoz LCF (adalimumab-adaz) SC, Abrilada (adalimumab-afzb) SC, Hulio (adalimumab-fkjp) SC, Yusimry (adalimumab-aqvh) SC, Hadlima (adalimumab-bwwd) SC and Yuflyma (adalimumab-aaty) SC
- Treatment of hidradenitis suppurativa, pyoderma gangrenosum, and uveitis as non-preferred products and with the identical coverage criteria as Amjevita (adalimumab-atto) [NDCs starting with 72511]
Medical necessity criteria added
- Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc)
- Treatment of generalized myasthenia gravis in adult individuals who are anti-acetylcholine receptor antibody positive
Prostate Cancer Targeted Therapies, 5.01.544 PBC | Premera HMO
Medical necessity criteria added
- Zytiga (abiraterone)
- Treatment of deleterious or suspected deleterious BRCA-mutated (BRCAm) metastatic castration-resistant prostate cancer when used in combination with prednisone and olaparib
- Generic abiraterone
- Treatment of deleterious or suspected deleterious BRCAm metastatic castration-resistant prostate cancer when used in combination with prednisone and olaparib
Spravato (esketamine) Nasal Spray, 5.01.609 PBC | Premera HMO
Medical necessity criteria updated
- Spravato (esketamine)
- New course of Spravato requires individuals to have had a positive response to the previous course of treatment with Spravato
Gonadotropin Releasing Hormone (GnRH) Analogs, 5.01.625 PBC | Premera HMO
Gender dysphoria
Drug added
- Eligard (leuprolide acetate)
Medical necessity criteria updated
- Requires documentation of individual’s gender incongruence and desire to be of a gender other than the individual’s assigned gender are not due to any other psychiatric disorders (e.g., psychotic disorders)