July Provider Notification

Policy 

Policy Name 

Revision 

Effective Date 

CP.PHAR.121 

Nivolumab, Nivolumab Hyaluronidase-nvhy (Opdivo, Opdivo Qvantig) 

HCPCS code added [J9289]; RT4: updated FDA Approved Indication(s) section and criteria to reflect revised indication that limits use to tumors expressing PD-L1 (≥ 1) in combination with chemotherapy for unresectable advanced or metastatic ESCC in first-line setting and gastric cancer, GEJ cancer and esophageal adenocarcinoma (previously approved regardless of PD-L1 status); also for MSI-H or dMMR esophageal cancers, specified usage as perioperative therapy when prescribed as a single age, as induction or palliative therapy when prescribed combination with fluoropyrimidine-containing chemotherapy, and as induction, neoadjuvant, perioperative, or palliative when prescribed in combination with Yervoy; updated Appendix F with revised language and exception for Tennessee. 

10/01/25 

CP.PHAR.319 

Ipilimumab (Yervoy) 

RT4: updated FDA Approved Indication(s) section and criteria to reflect revised indication that limits use to tumors expressing PD-L1 (≥ 1) for unresectable advanced or metastatic ESCC in combination with Yervoy per updated PI (previously approved regardless of PD-L1 status); also for ESCC, added option to be prescribed as palliative therapy and clarified when prescribed as induction, neoadjuvant, perioperative, or palliative therapy that tumor is characterized as MSI-H or dMMR.  

10/01/25 

CP.PHAR.367 

Letermovir (Prevymis) 

For prophylaxis of CMV in kidney transplant recipients, added criterion limiting usage of Prevymis up to day 200 post-transplantation. 

10/01/25 

CP.PHAR.605 

Adagrasib (Krazati) 

Per SDC for CRC, added redirection to Lumakras; for NCSLC and CRC, added step therapy bypass for IL HIM per IL HB 5395. 

10/01/25 

CP.PMN.192 

Brimonidine (Mirvaso) 

Added redirection for brand Mirvaso requests to generic topical brimonidine. 

10/01/25