Revised pharmacy policies
Effective February 14, 2018
Exondys 51® (eteplirsen), 5.01.570
Immune Globulin Therapy, 8.01.503
Nulojix® (belatacept) for Adults, 5.01.536
Pharmacotherapy of Miscellaneous Autoimmune Disease, 5.01.564
Rituximab: Non-oncologic and Miscellaneous Uses, 5.01.556
Site of Service: Infusion Drugs and Biologic Agents, 11.01.523
Soliris® (eculizumab), 5.01.571
Pharmacotherapy of Arthropathies, 5.01.550
Approval of site-of-service administration is expanded to 90 days for initial infusion. The medical necessity criteria statements were update as follows:
- The Xeljanz® (tofacitinib) /Xeljanz XR® criteria were updated for rheumatoid arthritis.
- Xeljanz/Xeljanz XR were added as a first-line agent for psoriatic arthritis when criteria are met.
- Taltz™ (ixekizumab) was added as a second-line agent for psoriatic arthritis and may be approved when criteria are met.
- Taltz and Siliq™ (ixekizumab) criteria for psoriatic arthritis were changed to state that in addition to existing criteria, these agents need to be prescribed by or in consultation with a dermatologist.
Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563
Approval of site-of-service administration is expanded to 90 days for initial infusion. The policy was revised to move Stelara® (ustekinumab) from a second-line agent to a first-line agent for Crohn disease; the mandatory use of Humira® (adalimumab) for this indication was removed.
Effective March 1, 2018
Kalydeco® (ivacaftor), Orkambi® (lumacaftor/ivacaftor), and Symdeko™ (tezacaftor/ivacaftor), 5.01.539
The policy was revised to add Symdeko™ (tezacaftor/ivacaftor) for the treatment of cystic fibrosis in patients 12 years old and older when criteria are met.
Excessively High Cost Drug Products with Lower Cost Alternatives, 5.01.560
Brand name topical lidocaine products are not medically necessary unless there are documented failures of topical generic lidocaine products.
Medical Necessity Criteria for Pharmacy Edits, 5.01.605
The policy was revised to add Adzenys ER™ (amphetamine) to the list of brand stimulants requiring review for the treatment of ADHD and other psychiatric conditions.
Miscellaneous Oncology Drugs, 5.01.540
The policy was revised to add a statement of medical necessity and the criteria for Lynparza™ (olaparib) for gBRCAm, HER2-negative metastatic breast cancer.
Pharmacologic Treatment of Neuropathy, Fibromyalgia, and Seizure Disorders, 5.01.521
The criteria were updated to include coverage of Lyrica® CR (pregabalin extended release) for adults with diabetic peripheral neuropathy or postherpetic neuralgia when criteria are met.
Pharmacotherapy of Type 1 and Type II Diabetes Mellitus, 5.01.569
The policy was revised to add Admelog® (lispro) and Admelog Solostar® (lispro) as nonpreferred rapid acting insulin products. Steglatro® (ertugliflozin) is now a preferred SGLT-2 agent.