July Provider Notification

Policy

Policy Name

Revision

Effective Date

CP.PHAR.759

Nerandomilast (Jascayd)

Per March SDC, for IPF added redirection through both generic pirfenidone and Ofev; for PPF added redirection through Ofev

9/1/2026

CP.PHAR.103

Immune Globulins

2Q 2026 annual review: for CAR-T cell-related toxicities, added use for AIDP-type picture or bilateral facial palsy per NCCN; added off-label indications for immune checkpoint inhibitor-related toxicities, LCHI/ND, HIT, and pediatric ALL per NCCN; added HCPCS code [J1553]; references reviewed and updated.

9/1/2026

CP.PHAR.140

Pegvaliase-pqpz (Palynziq)

2Q 2026 annual review: bringing forward to align with the annual review cycle for Kuvan; added adherence to Phe-restricted diet per plan feedback and align with Sephience criteria; references reviewed and updated

9/1/2026

CP.PHAR.236

Darbepoetin Alfa (Aranesp)

For UC, added Mayo Endoscopic Score > 2; for AS, CD, PsO, RA, and UC, added bypass of conventional therapies if failed a biologic agent.
Extended initial approval durations to 12 months for chronic conditions.

9/1/2026

CP.PHAR.237

Epoetin Alfa (Epogen, Procrit), Epoetin Alfa-epbx (Retacrit)

2Q 2026 annual review: for continuation of therapy request for anemia associated with CKD, modified current hemoglobin requirement from ≤ 12 g/dL to ≤ 11.5 g/dL; for anemia associated with CKD, added requirement that requested product is not prescribed concurrently with a hypoxia-inducible factor prolyl hydroxylase (HIF PH) inhibitor; references reviewed and updated.

9/1/2026

CP.PHAR.238

Methoxy Polyethylene Glycol-Epoetin Beta (Mircera)

2Q 2026 annual review: for continuation of therapy request modified current hemoglobin requirement from ≤ 12 g/dL to ≤ 11.5 g/dL; added requirement that requested product is not prescribed concurrently with a hypoxia-inducible factor prolyl hydroxylase (HIF PH) inhibitor; references reviewed and updated.

9/1/2026

CP.PHAR.316

Cabazitaxel (Jevtana)

2Q 2026 annual review: per NCCN compendium for off-label use in small cell/neuroendocrine prostate cancer clarified that Jevtana is prescribed in combination with carboplatin with concurrent steroid; revised initial approval duration for Medicaid/HIM from 6 to 12 months; references reviewed and updated.

9/1/2026

CP.PHAR.416

Caplacizumab-yhdp (Cablivi)

For UC, added Mayo Endoscopic Score > 2; added bypass of conventional therapies if failed a biologic agent.
Extended initial approval durations to 12 months for chronic conditions.

9/1/2026

CP.PHAR.533

Ciltacabtagene Autoleucel (Carvykti)

2Q 2026 annual review: per NCCN added additional approval pathway after ≥ 3 prior lines of therapy that also includes one anti-CD38 antibody; references reviewed and updated.

9/1/2026

CP.PHAR.573

Cabotegravir, Cabotegravir-Rilpivirine (Apretude, Cabenuva)

2Q 2026 annual review: per NCCN added additional approval pathway after ≥ 3 prior lines of therapy that also includes one anti-CD38 antibody; references reviewed and updated.

9/1/2026

CP.PHAR.582

Lutetium Lu 177 vipivotide tetraxetan (Pluvicto)

2Q 2026 annual review: added Erleada and Nubeqa as additional examples of androgen receptor pathway inhibitors that would qualify to satisfy prior therapy requirements; for continuation of therapy added requirement that member continues to use a GnRH analog concurrently or has had a bilateral orchiectomy; references reviewed and updated.

9/1/2026