Policy
| Policy Name
| Revision
| Effective Date
|
CP.PHAR.322
| Pembrolizumab (Keytruda)
| 3Q 2025 annual review: for NSCLC, updated targeted therapies for EGFR exon 19 deletion, L858R, and ROS1 rearrangement positive disease; for HNSCC added option to be prescribed in combination with Erbitux as first-line therapy or subsequent-line therapy; for cHL, added option to be prescribed in combination with decitabine and vorinostat, for post-allogenic hematopoietic cell transplant or post autologous stem cell rescue, and members not candidate for anthracycline therapy and revised for relapsed disease for both adults and pediatrics after ≥ 1 line of systemic therapy (previously ≥ 2 lines of systemic therapy for pediatrics); for UC, added option to be prescribed in combination with Inlyta or Lenvima, usage for relapsed disease, and prescribed as a single agent for adjuvant therapy; for cervical cancer, added FIGO 2018 stage III-IVA in combination with CRT and added option to be prescribed in combination with Tivdak for tumors expressing PD-L1 and has not received prior immune-oncology therapy, recurrent or metastatic disease, and disease as progressed on or after ≥ 1 line of systemic therapy; for HCC, removed specific treatment regimens member has had disease progression following from and revise to prescribed as subsequent line therapy; for BTC, added option for disease is resectable locoregionally advanced and prescribed as neoadjuvant therapy for gallbladder cancer; for TNBC, added option to be prescribed as preoperative systemic therapy in combination with carboplatin and docetaxel; added off-label usage for central nervous (CNS) cancer, thyroid carcinoma, peritoneal mesothelioma, penile cancer; for mycosis fungoides, revised stage to Stage IA – III; for thymic carcinoma, removed metastatic or unresectable requirement; RT4: updated FDA Approved Indication(s) section and criteria to reflect revised indication that limits use to tumors expressing PD-L1 (CPS ≥ 1) for esophageal or GEJ carcinoma in combination with chemotherapy and HER2-negative gastric or GEJ adenocarcinoma as first-line therapy in combination with chemotherapy per updated PI (previously approved regardless of PD-L1 status); RT4: updated FDA Approved Indications(s) section for cervical cancer to clarify FIGO 2014 Stage III-IVA per updated PI; updated Appendix E with addition of soft tissue sarcoma as an example for MSI-H solid tumors and small bowel adenocarcinoma for TMB-H solid tumors; updated Appendix G with revised language and exception for Tennessee; references reviewed and updated.
Per June SDC: added redirection to Tevimbra for HER2-negative gastric or GEJ adenocarcinoma and esophageal carcinoma or GEJ squamous cell carcinoma.
RT4: added new FDA approved indication for usage in the neoadjuvant/adjuvant setting for locally advanced HNSCC.
| 12/1/2025
|
CP.PHAR.415
| Ravulizumab-cwvz (Ultomiris)
| 3Q 2025 annual review: updated the list of therapies that Ultomiris should not be prescribed concurrently with to include Epysqli for all indications and PiaSky for PNH; for gMG, clarified that the required immunosuppressive therapy should be non-steroidal; revised continued approval duration from 6 to 12 months for all indications as they are chronic conditions; references reviewed and updated.
Added step therapy bypass for IL HIM per IL HB 5395.
| 12/1/2025
|
CP.PHAR.458
| Inebilizumab-cdon (Uplizna)
| 3Q 2025 annual review: for NMOSD, added Epysqli to the list of therapies that Uplizna should not be prescribed concurrently with, and revised continued approval duration from 6 to 12 months as NMOSD is a chronic condition; RT4: added criteria for the newly approved indication of IgG4-RD; references reviewed and updated.
Added step therapy bypass for IL HIM per IL HB 5395.
| 12/1/2025
|
CP.PHAR.495
| Mitomycin Instillation Solution (Jelmyto, Zusduri)
| 3Q 2025 annual review: removed requirement for cancer location above the ureteropelvic junction per NCCN; removed exclusion for “recent history of carcinoma in situ in the urinary tract, invasive urothelial carcinoma, or high-grade papillary urothelial carcinoma” as this is not excluded per NCCN or the FDA indication; added requirement for use as monotherapy per NCCN; references reviewed and updated.
RT4: added criteria for newly approved Zusduri; policy renamed to “Mitomycin Instillation Solution.”
| 12/1/2025
|
CP.PHAR.121
| Nivolumab, Nivolumab Hyaluronidase-nvhy
| Per June SDC: for ESCC and gastric/GEJ adenocarcinoma, added redirection to Tevimbra.
| 12/1/2025
|
CP.PHAR.146
| Deferoxamine (Desferal)
| 3Q 2025 annual review: for chronic iron overload, revised concurrent iron chelator bypass threshold from cardiac T2* < 20 ms to mT2* ≤ 10 ms per TIF guidelines; references reviewed and updated
| 12/1/2025
|
CP.PHAR.295
| Sargramostim (Leukine)
| 3Q 2025 annual review: per NCCN Compendium for neuroblastoma removed requirement for relapse or refractory disease, clarified combination with Danyelza should also include temozolomide and irinotecan; added step therapy bypass for IL HIM per IL HB 5395; updated Appendix E with revised language and exception for Tennessee; references reviewed and updated.
| 12/1/2025
|
CP.PHAR.303
| Brentuximab Vedotin (Adcetris)
| 3Q 2025 annual review: per NCCN – for cHL, added option for use with CHP as alternative to AVD if vinblastine is unavailable due to shortage, added option for use with nivolumab for age > 60 years, revised requirements around use as component of BrECADD (removed requirement for stage III-IV disease, added option for use with Deauville score 4-5, added requirement for use with granulocyte colony-stimulating factor); for pediatric cHL, added option for use as a component of BrECADD and Bv-AVD for stage III-IV disease, specified that only use following high-dose therapy and autologous stem cell rescue has to be in high-risk disease, and modified requirement for high risk disease for nearly all requests to instead require risk factors only for stage I-II disease; for MF/Sezary syndrome, removed option for combination use with bendamustine; references reviewed and updated
| 12/1/2025
|
CP.PHAR.312
| Blinatumomab (Blincyto)
| 3Q 2025 annual review: per NCCN – clarified that Ph refers to adult disease and added the term BCR::ABL1 for pediatric disease; for pediatrics, removed pathways for use after consolidation therapy and added combination therapy option for BCR::ABL1-negative/like disease; for infant ALL, removed requirement for KMT2A status (11q23 rearranged); references reviewed and updated.
| 12/1/2025
|
CP.PHAR.424
| Fulvestrant (Faslodex Injection)
| 3Q 2025 annual review: for breast cancer, added triple negative disease option per NCCN; for ovarian, fallopian tube, and primary peritoneal cancer, endometrial carcinoma, and uterine cancer, added requirement for monotherapy per NCCN; references reviewed and updated.
| 12/1/2025
|
CP.PHAR.433
| Polatuzumab Vedotin-piiq (Polivy)
| 3Q 2025 annual review: per NCCN – for PTLD, removed specification that disease must be monomorphic and added option for use in combination with R-CHP for disease with IPI score ≥ 2; for second-line use, added that member is either not a candidate for CAR T-cell therapy or Polivy is prescribed as bridging therapy until CAR T-cell therapy becomes available and added option for use in combination with Lunsumio for non-transplant/CAR T-cell therapy candidates; references reviewed and updated.
| 12/1/2025
|
CP.PHAR.449
| Crizanlizumab-tmca (Adakveo)
| For hydroxyurea trial, added that documentation supports adherence to hydroxyurea for at least the past 6 months, examples of hydroxyurea contraindications and intolerances, and a bypass option requiring provider attestation of past adherence to hydroxyurea for ≥ 6 months at the maximum tolerated dose and ≥ 1 VOC while on the maximum tolerated dose; removed ICD-10-CM Codes section.
| 12/1/2025
|
CP.PHAR.463
| Satralizumab-mwge (Enspryng)
| 3Q 2025 annual review: added step therapy bypass for IL HIM per IL HB 5395; added Epysqli to the list of therapies that Enspryng
should not be prescribed concurrently with; revised continued approval duration from 6 to 12 months as NMOSD is a chronic condition; references reviewed and updated.
| 12/1/2025
|
CP.PHAR.524
| Pegcetacoplan (Empaveli, Syfovre)
| 3Q 2025 annual review: for PNH, added Epysqli and PiaSky to the list of therapies that Empaveli should not be prescribed concurrently with, added improvement of extravascular hemolysis as an example of positive response to therapy, and revised continued approval duration from 6 to 12 months as PNH is a chronic condition; updated Syfovre contraindications in Appendix C to include hypersensitivity per updated prescribing information; references reviewed and updated.
| 12/1/2025
|
CP.PHAR.540
| Dostarlimab-gxly (Jemperli)
| 3Q 2025 annual review: for EC, added that combination use with carboplatin/paclitaxel for advanced/recurrent disease may be followed by single agent use per FDA labeling and NCCN; for solid tumors, removed option for early-stage gastric cancer, added option for locally unresectable, medically inoperable, or POLE/POLD1 mutated small bowel adenocarcinoma, and clarified that POLE/POLD1 mutation should have ultra-hypermutated phenotype per NCCN; added off-label criteria for anal carcinoma per NCCN; references reviewed and updated.
| 12/1/2025
|
CP.PHAR.545
| Betibeglogene Autotemcel (Zynteglo)
| 3Q 2025 annual review: no significant changes; added template statement requiring medical director review; added criterion for documentation of member’s body weight for verification of weight-based dose; references reviewed and updated.
| 12/1/2025
|
CP.PHAR.592
| Beremagene geperpavec-svdt (Vyjuvek)
| 3Q 2025 annual review: added exclusion of concomitant use with Zevaskyn; references reviewed and updated.
| 12/1/2025
|
