November Provider Notification
Date: 11/21/25
Arkansas Total Care is amending or implementing new policies. Please see the table below for a list of these policies and their effective dates.
Policy | Policy Name | Revision | Effective Date |
CP.PHAR.241 | Abatacept (Orencia) | For PsA, applied step therapy to Otezla for pediatric age redirection as Otezla has a newly approved pediatric extension for 6 years and older; for pJIA and RA, added bypass of conventional therapies if a member has failed a biologic agent to clarify intention of not stepping back from biologic agent to conventional therapy. | 3/1/2026 |
CP.PHAR.246 | Canakinumab (Ilaris) | For sJIA, added bypass of conventional therapies if a member has failed a biologic agent to clarify intention of not stepping back from biologic agent to conventional therapy. | 3/1/2026 |
CP.PHAR.253 | Golimumab (Simponi, Simponi Aria) | For PsA, applied step therapy to Otezla for pediatric age redirection as Otezla has a newly approved pediatric extension for 6 years and older; for UC, added option for Mayo Endoscopic Score > 2 to define moderate-to-severe UC; for AS, pJIA, RA, and UC, added bypass of conventional therapies if a member has failed a biologic agent to clarify intention of not stepping back from biologic agent to conventional therapy. | 3/1/2026 |
CP.PHAR.254 | Infliximab (Avsola, Inflectra, Remicade, Renflexis, Zymfentra) | For UC, added option for Mayo Endoscopic Score > 2 to define moderate-to-severe UC; for AS, CD, PsO, RA, and UC, added bypass of conventional therapies if a member has failed a biologic agent to clarify intention of not stepping back from biologic agent to conventional therapy. | 3/1/2026 |
CP.PHAR.259 | Natalizumab (Tysabri, Tyruko) | For CD, added bypass of conventional therapies if a member has failed a biologic agent to clarify intention of not stepping back from biologic agent to conventional therapy. | 3/1/2026 |
CP.PHAR.260 | Rituximab (Rituxan, Riabni, Ruxience, Truxima, Rituxan Hycela) | Per SDC, added off-label criteria for bullous pemphigoid; for RA, added bypass of conventional therapies if a member has failed a biologic agent to clarify intention of not stepping back from biologic agent to conventional therapy; removed Castleman Disease from B-cell lymphoma initial approval criteria as Castleman Disease is not categorized as B-cell lymphoma per NCCN and added Castleman Disease to NCCN Compendium Indications (off-label) initial approval criteria. | 3/1/2026 |
CP.PHAR.263 | Tocilizumab (Actemra) Actemra biosimilars | RT4: for Avtozma, added newly approved CRS indication to criteria; RT4: for Actemra, updated indication for COVID-19 to include pediatric extension; for CRS, GCA, sJIA, and Castleman’s disease, added redirection from biosimilars to preferred agent Actemra; for GCA, pJIA, RA, and sJIA, added bypass of conventional therapies if a member has failed a biologic agent to clarify intention of not stepping back from biologic agent to conventional therapy; added HCPCS code Q5156 for Avtozma. | 3/1/2026 |
CP.PHAR.264 | Ustekinumab (Stelara and biosimilars) | For UC, added option for Mayo Endoscopic Score > 2 to define moderate-to-severe UC; added bypass of conventional therapies if a member has failed a biologic agent to clarify intention of not stepping back from biologic agent to conventional therapy. | 3/1/2026 |
CP.PHAR.265 | Vedolizumab (Entyvio) | For UC, added option for Mayo Endoscopic Score > 2 to define moderate-to-severe UC; added bypass of conventional therapies if a member has failed a biologic agent to clarify intention of not stepping back from biologic agent to conventional therapy. | 3/1/2026 |
CP.PHAR.317 | Cetuximab (Erbitux) | 4Q 2025 annual review: per NCCN, for HNSCC, added option for use if member is receiving reirradiation with concurrent radiotherapy; for CRC, replaced “unresectable” with “recurrent,” specified that POLE/POLD1 mutation positive disease must have ultra-hypermutated phenotype, removed prior therapy requirement when prescribed for BRAF V600E mutation positive in combination with Braftovi and added clarification that regimen may be “with or without FOLFOX,” and modified requirement for left-sided colon cancer to also apply to unresectable metachronous metastases; for NSCLC, simplified criterion requiring disease progression on prior therapy to no longer call out T790M positive disease; extended initial approval duration for HIM/Medicaid from 6 to 12 months; revised approval durations for Commercial from 6/12 months to standard injectable authorization of “6 months or to the member’s renewal date, whichever is longer”; references reviewed and updated | 3/1/2026 |
CP.PHAR.321 | Panitumumab (Vectibix) | 4Q 2025 annual review: specified that POLE/POLD1 mutation positive disease must have ultra-hypermutated phenotype and specified that unresectable synchronous metastases are in the liver and/or lung per NCCN; extended initial approval duration for HIM/Medicaid from 6 to 12 months; revised approval durations for Commercial from 6/12 months to standard injectable authorization of “6 months or to the member’s renewal date, whichever is longer”; references reviewed and updated. | 3/1/2026 |
CP.PHAR.367 | Letermovir (Prevymis) | Added criterion Prevymis must be initiated within 7 days post kidney transplant and 28 days post HSCT per PI. | 2/1/2026 |
CP.PHAR.397 | Cemiplimab-rwlc (Libtayo) | 4Q 2025 annual review: for CSCC, added option for disease that is satellitosis/in-transit metastasis that is unresectable or incompletely resected per NCCN; for cervical, vaginal cancer and vulvar cancer, clarified usage as second-line or subsequent therapy per NCCN; added off-label indications for anal carcinoma and dMMR/MSI-H or POLE/POLD1 mutation with tumor cancers for: small bowel adenocarcinoma, and rectal and colon cancer per NCCN; initial approval durations changed from 6 to 12 months for Medicaid/HIM; references reviewed and updated. | 3/1/2026 |
CP.PHAR.426 | Risankizumab-rzaa (Skyrizi) | For UC, added option for Mayo Endoscopic Score > 2 to define moderate-to-severe UC; for PsO, CD, and UC, added bypass of conventional therapies if a member has failed a biologic agent to clarify intention of not stepping back from biologic agent to conventional therapy; RT4: added new 180 mg/1.2 mL single-dose prefilled syringe dosage form and strength; for CD and UC criteria, added “if request is for vials/cartridges” to clarify quantity limit applies to vial/cartridge requests only. | 3/1/2026 |
CP.PHAR.58 | Denosumab (Prolia, Xgeva and biosimilars) | Per August SDC: for multiple myeloma or solid tumor, giant cell tumor of bone, hypercalcemia of malignancy, systemic mastocytosis, added redirection to Osenvelt and Wyost if request is for a product other than Osenvelt and Wyost for initial and continuation of therapy requests. | 3/1/2026 |
CP.PHAR.662 | Mirikizumab-mrkz (Omvoh) | For UC, added option for Mayo Endoscopic Score > 2 to define moderate-to-severe UC; for CD and UC, added bypass of conventional therapies if a member has failed a biologic agent to clarify intention of not stepping back from biologic agent to conventional therapy. | 3/1/2026 |