March Provider Notification

Policy

Policy Name

Revision

Effective Date

CP.PHAR.264

Ustekinumab (Stelara and biosimilars)

RT4: added newly approved biosimilar Yesintek to criteria; RT4: for Pyzchiva, added new dosage formulation [single-dose vial for SC injection 45 mg/0.5 mL]; for PsO and PsA, added Pyzchiva to “weight < 60 kg: 0.75 mg/kg per dose” pediatric dosing criteria; RT4: for Wezlana, added new dosage formulation [single-dose prefilled autoinjector (ConfiPen) 45 mg/0.5 mL, 90 mg/mL]; RT4: added newly approved biosimilar Steqeyma to criteria. 

6/1/2025

CP.PHAR.171

Goserelin Acetate (Zoladex)

For gender dysphoria and gender transition, added requirement for provider attestation of understanding current State regulations regarding transgender-related health care and such care is coverable under the State regulations, added to Appendix D link and notation that the Movement Advancement Project can be referenced to confirm transgender-related health care is coverable under the State regulations. 

6/1/2025

CP.PHAR.172

Histrelin Acetate (Vantas, Supprelin LA)

For gender dysphoria and gender transition, added requirement for provider attestation of understanding current State regulations regarding transgender-related health care and such care is coverable under the State regulations, added to Appendix D link and notation that the Movement Advancement Project can be referenced to confirm transgender-related health care is coverable under the State regulations. 

6/1/2025

CP.PHAR.173

Leuprolide Acetate (Eligard, Fensolvi, Lupron Depot, Lupron Depot-Ped), Leuprolide mesylate (Camcevi)

For gender dysphoria and gender transition, added requirement for provider attestation of understanding current State regulations regarding transgender-related health care and such care is coverable under the State regulations, added to Appendix D link and notation that the Movement Advancement Project can be referenced to confirm transgender-related health care is coverable under the State regulations. 

6/1/2025

CP.PHAR.175

Triptorelin Pamoate (Trelstar, Triptodur)

For gender dysphoria and gender transition, added requirement for provider attestation of understanding current State regulations regarding transgender-related health care and such care is coverable under the State regulations, added to Appendix D link and notation that the Movement Advancement Project can be referenced to confirm transgender-related health care is coverable under the State regulations. 

6/1/2025

CP.PHAR.354

Testosterone (Testopel, Jatenzo, Kyzatrex, Tlando)

For gender dysphoria and gender transition, added requirement for provider attestation of understanding current State regulations regarding transgender-related health care and such care is coverable under the State regulations, added to Appendix D link and notation that the Movement Advancement Project can be referenced to confirm transgender-related health care is coverable under the State regulations. 

6/1/2025      

CP.PHAR.593

Delandistrogene Moxeparvovec-rokl (Elevidys)

Removed HIM and Commercial lines of business; restricted Elevidys to age to 4 years through 5 years; added member does not have an active infection; added member has all of the following assessed within the last 30 days: stable cardiac function with LVEF ≥ 40%, baseline liver function tests with absence of significant liver dysfunction, and baseline platelet count and baseline troponin I; added disclaimer for non-ambulatory members to refer to Section III; added member has not been previously treated with the investigational agent deramiocel (CAP-1002).

6/1/2025