September Provider Notification
Date: 09/29/26
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.506 | Antithymocyte Globulin (Atgam, Thymoglobulin) | 4Q 2026 annual review: added ICHRA line of business; for Atgam, added option to be prescribed for GVHD prophylaxis per NCCN; references reviewed and updated. | 12/1/2026 |
| CP.PHAR.691 | Axatilimab-csfr (Niktimvo) | 4Q 2026 annual review: added ICHRA line of business; added 9 mg/0.9 mL and 22 mg/2.2 mL dosage strengths; references reviewed and updated. | 12/1/2026 |
| CP.PHAR.387 | Azacitidine (Vidaza, Onureg) | 4Q 2026 annual review: for myelodysplastic syndromes and myeloproliferative neoplasms, clarified that requests for generic azacitidine should be for the SC/IV formulation; for peripheral T-cell lymphomas, added progressive as an additional disease qualifier option per NCCN; added off-label criteria for Onureg for T-cell acute lymphoblastic leukemia per NCCN; added ICHRA line of business; updated Appendix E with revised language for Tennessee; references reviewed and updated. | 12/1/2026 |
| CP.PHAR.307 | Bendamustine (Belrapzo, Bendeka, Treanda, Vivimusta) | 4Q 2026 annual review: added ICHRA line of business; for DLBCL and high-grade B-cell lymphomas, removed specification for intention to proceed to transplant; for pediatric HL, removed “as re-induction or subsequent therapy” per NCCN; references reviewed and updated. | 12/1/2026 |
| CP.PHAR.93 | Bevacizumab (Alymsys, Avastin, Avzivi, Jobevne, Lytenava, Mvasi, Vegzelma, Zirabev) | 4Q 2026 annual review: added ICHRA line of business; updated Appendix E with revised language for Tennessee; for RCC, added option for use in combination with interferon alfa per FDA label; for the following oncology indications, revised the following per NCCN: added use in appendiceal neoplasms and cancers, clarified glioblastoma includes gliosarcoma, added use in NF2-related schwannomas, removed prescribed by in combination with IROX for CRC, for epithelial ovarian, fallopian tube, and primary peritoneal cancer, added use in combination with paclitaxel for small cell carcinoma (hypercalcemic type) recurrence therapy, added use in combination with FOLFIRI for platinum-resistant disease, added use in combination with paclitaxel and Keytruda for platinum-resistant disease; for ophthalmology uses, revised maximum dose for off-label uses to 1.25 mg per AAO guidelines and Clinical Pharmacology; RT4: added newly approved intravitreal formulation Lytenava for nAMD; separated FDA approved indication sections into oncology indications and ophthalmology indications; for oncology indications, added criterion that request is for Avastin, Alymsys, Avzivi, Jobevne, Mvasi, Vegzelma, or Zirabev; references reviewed and updated. | 12/1/2026 |
| CP.PHAR.309 | Carfilzomib (Kyprolis) | 4Q 2026 annual review: added ICHRA line of business; for WM/LPL, added option to be prescribed for previously treated disease per NCCN; references reviewed and updated. | 12/1/2026 |
| CP.PHAR.397 | Cemiplimab-rwlc (Libtayo) | 4Q 2026 annual review: for off-label uses, added additional use as neoadjuvant therapy for small bowel adenocarcinoma, clarified that use in rectal and colon cancer should be in those with no previous treatment with checkpoint inhibitor/immunotherapy, added use in appendiceal cancer, and added additional use for combination or single agent therapy for anal carcinoma per NCCN; added ICHRA line of business; references reviewed and updated. | 12/1/2026 |
| CP.PHAR.317 | Cetuximab (Erbitux) | 4Q 2026 annual review: per NCCN – for CRC, clarified that use as a single agent or in combination with FOLFIRI, FOLFOX, CapeOX or irinotecan is only for KRAS/NRAS/BRAF wild-type disease, added options for use in combination with Braftovi with or without FOLFIRI or CapeOx for BRAF V600E mutation positive disease, allowed use as initial therapy in combination with Lumakras or Krazati for KRAS G12C mutation positive disease, limited to left-sided cancer only for initial therapy requests for KRAS/NRAS/BRAF wild-type colon cancer, and clarified that disease is either dMMR/MSI-H/POLE/POLD1 or pMMR/MSS; added off-label criteria for appendiceal cancers and small bowel adenocarcinoma; added ICHRA line of business; references reviewed and updated. | 12/1/2026 |
| CP.PHAR.567 | Cipaglucosidase alfa-atga--miglustat (Pombiliti-Opfolda) | Updated NPC diagnostic criterion to require confirmation by biallelic pathogenic variants in NPC1 or NPC2 gene per updated international consensus guidelines; added ICHRA line of business. | 12/1/2026 |
| CP.PHAR.385 | Corticosteroids for Ophthalmic Injection (Dextenza, Iluvien, Ozurdex, Retisert, Xipere, Yutiq) | Added step through of intravitreal steroid injections back to all indications as Triesence is now available for macular edema and DME. | 12/1/2026 |
| CP.PHAR.799_PEPP | Delpacibart Zotadirsen (AOC 1044)_PEPP | Policy created pre-emptively | 12/1/2026 |
| CP.PHAR.318 | Eribulin mesylate (Halaven) | 4Q 2026 annual review: for STS, added borderline/malignant phyllodes tumor of breast subtype and added subsequent therapy bypass for liposarcoma and epithelioid hemangioendothelioma subtype per NCCN; added ICHRA line of business; references reviewed and updated. | 12/1/2026 |
| CP.PHAR.808 | Gedatolisib (Revtorpyk) | Policy created | 12/1/2026 |
| CP.PHAR.753 | Gemcitabine Intravesical System (Inlexzo) | 4Q 2026 annual review: added ICHRA line of business; added option for use in NMBIC with Ta or T1 papillary tumors per NCCN; references reviewed and updated. | 12/1/2026 |
| CP.PHAR.171 | Goserelin Acetate (Zoladex) | 4Q 2026 annual review: added ICHRA line of business; for ovarian cancer, salivary gland tumors, and uterine sarcoma added requirement for age ≥ 18 years; per NCCN compendium for ovarian cancer added requirement prescribed as a single agent; per NCCN compendium for salivary gland tumors added requirement prescribed as a single agent or in combination with abiraterone and prednisone; references reviewed and updated. | 12/1/2026 |
| CP.PHAR.131 | Infertility and Fertility Preservation | 4Q 2026 annual review: added ICHRA line of business; removed each states specific evidence of coverage language (EOC) and instead added language to refer to plan specific EOC document for benefit coverage; for female infertility and fertility preservation, added criterion that member is premenopausal; added off-label criteria for steroid-refractory acute graft-versus-host disease as supported by NCCN; references reviewed and updated, | 12/1/2026 |
| CP.PHAR.596 | Lecanemab-irmb (Leqembi, Leqembi Iqlik) | 4Q 2026 annual review: added the new indication for Leqembi Iqlik for treatment initiation; references reviewed and updated. | 12/1/2026 |
| CP.PHAR.173 | Leuprolide Acetate (Lupron, Eligard, Lupaneta Pack, Fensolvi, Camcevi, Vabrinty) | 4Q 2026 annual review: added requirement for age ≥ 18 years for salivary gland tumors and uterine sarcoma; per NCCN compendium for breast cancer added requirement that member is premenopausal or male and prescribed in combination with endocrine therapy; updated Appendix E with revised language for Tennessee; added S9560 HCPCS code; references reviewed and updated. | 12/1/2026 |
| CP.PHAR.802_PEPP | Medoretgene parvec (AAV-AIPL1)_PEPP | Policy created pre-emptively | 12/1/2026 |
| CP.PHAR.139 | Mogamulizumab-kpkc (Poteligeo) | 4Q 2026 annual review: for ATLL initial therapy, removed “prescribed as a single agent” and added option for use in combination with CHOP per NCCN; added ICHRA line of business; references reviewed and updated. | 12/1/2026 |
| CP.PHAR.461 | Nadofaragene firadenovec-vncg (Adstiladrin) | 4Q 2026 annual review: increased initial and continued therapy approval duration to 12 months for this maintenance medication for a chronic condition; references reviewed and updated. | 12/1/2026 |
| CP.PHAR.684 | Nogapendekin alfa inbakicept-pmln (Anktiva) | 4Q 2026 annual review: extended initial approval duration from 6 months to 12 months for this chronic condition; references reviewed and updated. | 12/1/2026 |
| CP.PHAR.305 | Obinutuzumab (Gazyva) | 4Q 2026 annual review: separated FL criteria from “B-Cell Lymphomas and Tumors with B-Cell Predominance” and renamed existing criteria “Additional NCCN Recommended Uses (off-label);” for CLL/SLL, added treatment option combinations for first-line therapy and histologic (Richter) transformation per NCCN; for FL, added NCCN-supported regimens for second-line and subsequent therapy; added indication of Waldenstrom macroglobulinemia/lymphoplasmacytic lymphoma per NCCN; for mantle cell lymphoma, added option for use as a substitute for rituximab at provider’s discretion per NCCN; added ICHRA line of business; references reviewed and updated. | 12/1/2026 |
| CP.PHAR.536 | Ophthalmic Riboflavin (Photrexa, Photrexa Viscous, Epioxa HD, Epioxa) | Added Epioxa HD and Epioxa to criteria per local market request. | 12/1/2026 |
| CP.PHAR.321 | Panitumumab (Vectibix) | 4Q 2026 annual review: added ICHRA line of business; added off-label small bowel adenocarcinoma and appendiceal neoplasms and cancers per NCCN; for CRC per NCCN, removed specification for BRAF V600E mutation positive disease for use in combination with Braftovi, removed specification for KRAS G12C positive disease for use in combination with Lumakras or Krazati; references reviewed and updated. | 12/1/2026 |
| CP.PHAR.513 | Plasminogen (Ryplazim) | 4Q 2026 annual review: revised diagnostic criteria to clarify “PLG mutation” as “biallelic mutations in the PLG gene,” to require signs/symptoms of C-PGLD, and to meet either the plasminogen activity level ≤ 45% or the biallelic mutations in PLG gene as a diagnostic criterion; added ICHRA line of business; references reviewed and updated. | 12/1/2026 |
| CP.PHAR.314 | Romidepsin (Istodax) | 4Q 2026 annual review: for initial therapy, added bypass of failure of one prior systemic therapy for subcutaneous panniculitis-like T-cell lymphoma per NCCN; added ICHRA line of business; references reviewed and updated. | 12/1/2026 |
| CP.PHAR.648 | Rozanolixizumab-noli (Rystiggo) | 4Q 2026 annual review: for gMG, added Imaavy and Uplizna to the list of therapies that Rystiggo should not be prescribed concurrently with; added ICHRA line of business; references reviewed and updated. | 12/1/2026 |
| CP.PHAR.649 | Talquetamab-tgvs (Talvey) | 4Q 2026 annual review: added ICHRA line of business; added option to be prescribed as bridge to BCMA CAR-T therapy per NCCN; references reviewed and updated. | 12/1/2026 |
| CP.PHAR.324 | Temsirolimus (Torisel) | 4Q 2026 annual review: for soft tissue sarcoma, added option for pediatric rhabdomyosarcoma indication per NCCN; added age bypass for pediatric rhabdomyosarcoma; added ICHRA line of business; references reviewed and updated. | 12/1/2026 |
| CP.PHAR.561 | Tisotumab vedotin-tftv (Tivdak) | 4Q 2026 annual review: removed monotherapy requirement from continued therapy; added ICHRA line of business; references reviewed and updated. | 12/1/2026 |
| CP.PHAR.175 | Triptorelin pamoate (Trelstar, Triptodur) | 4Q 2026 annual review: added ICHRA line of business; for breast cancer, salivary gland tumors, and uterine sarcoma added requirement for age ≥ 18 years; per NCCN compendium for breast cancer added requirement that member is premenopausal or male and prescribed in combination with endocrine therapy; references reviewed and updated. | 12/1/2026 |
| CP.PHAR.439 | Valrubicin (Valstar) | 4Q 2026 annual review: added ICHRA line of business; removed specification of CIS disease; added option for use as subsequent treatment for muscle invasive disease in combination with TURBT per NCCN; added option for use in CIS, Ta, or T1 local recurrence or persistent disease in a preserved bladder for disease treated with curative intent per NCCN; references reviewed and updated. | 12/1/2026 |
| CP.PHAR.804_PEPP | Zeleciment rostudirsen (DYNE-251)_PEPP | Policy created pre-emptively | 12/1/2026 |