Medical Policy Updates

Medical Policy Update April 28, 2021

Medical Policy Revision
Abatacept (Orencia®) Addition of criteria for history of use of another biologic immunomodulator agent (or Otezla) for the same indication; RA: added requirement for trial of methotrexate or another conventional agent; PsA: added requirement for trial of one conventional agent, added option for severe active PsA or concomitant severe psoriasis; PJIA: added requirement for trial of one conventional agent; added requirements to be prescribed by or in consultation with a specialist, that patient has no FDA labeled contraindications, and for TB testing; added maximum units; medical policy formatting change. Policy notification given 2/26/2021 for effective date 4/28/2021.
Belimumab (Benlysta®) Removed criteria point regarding continuing standard therapy, removed requirement of no evidence of renal disease and/or central nervous system disease, added continuation criteria, added maximum units, medical policy formatting change. Policy notification given 2/26/2021 for effective date 4/28/2021.
Botulinum Toxin Injection Added specific age requirements according to indication where appropriate; Chronic anal fissure: added requirement of trial and failure of one conventional therapy; Chronic migraine: added criteria that patient has been evaluated for and does not have medication overuse headache; Sialorrhea: added requirement that patient has experienced excessive salivation for ≥3 months, and added trial and failure of at least one convention agent, added requirement of trial and failure of preferred Xeomin for Botox/Myobloc requests; OAB/urinary incontinence: added option of trial and failure of a beta-3 adrenergic agonist (Myrbetriq); combined coverage criteria for severe axillary or palmar hyperhidrosis into this policy; added maximum units/visits; medical policy formatting change. Policy notification given 2/26/2021 for effective date 4/28/2021.
Certolizumab pegol (Cimzia®) Addition of criteria for history of use of another biologic immunomodulator agent (or Otezla) for the same indication; RA: added option for trial of another conventional agent; PsA: added option for severe active PsA or concomitant severe psoriasis; PS: BSA requirement changed to 10%, added option for concomitant severe PsA; AS: added requirement for trial of two different NSAIDs or intolerance/contraindication/hypersensitivity to all NSAIDs; nr-axSpA: removed diagnostic criteria and requirement for objective signs of inflammation and radiographic evidence of structural damage; added requirements to be prescribed by or in consultation with a specialist, that patient has no FDA labeled contraindications, and for TB testing; added maximum units; medical policy formatting change. Policy notification given 2/26/2021 for effective date 4/28/2021.
Golimumab (Simponi Aria®) Addition of criteria for history of use of another biologic immunomodulator agent (or Otezla) for the same indication; RA: added option for trial of another conventional agent, added requirement to be taken in combination with methotrexate; PsA: added requirement for trial of one conventional agent, added option for severe active PsA or concomitant severe psoriasis; AS: added requirement for trial of two different NSAIDs or intolerance/contraindication/hypersensitivity to all NSAIDs; PJIA: added requirement for trial of one conventional agent; added requirements to be prescribed by or in consultation with a specialist, that patient has no FDA labeled contraindications, and for TB testing; added maximum units; medical policy formatting change. Policy notification given 2/26/2021 for effective date 4/28/2021.
Guselkumab (Tremfya®) Addition of criteria for history of use of another biologic immunomodulator agent (or Otezla) for the same indication; BSA requirement changed to 10%, added option for concomitant severe PsA; added requirement that patient has no FDA labeled contraindications, and for TB testing; added maximum units; medical policy formatting change. Policy notification given 2/26/2021 for effective date 4/28/2021.
Infliximab (Remicade®) and Infliximab Biosimilars Addition of criteria for history of use of another biologic immunomodulator agent (or Otezla) for the same indication; RA: added requirement for trial of methotrexate or another conventional agent; PS: added option for concomitant severe PsA; PsA: added requirement for trial of one conventional agent, added option for severe active PsA or concomitant severe psoriasis; CD: added requirement for trial of one conventional agent; added requirements to be prescribed by or in consultation with a specialist, and for TB testing; added maximum units; medical policy formatting change. Policy notification given 2/26/2021 for effective date 4/28/2021.
Interleukin-5 Antagonists Added requirement of a trial and failure of an oral immunosuppresant for diagnosis of EGPA/Churg-Strauss Syndrome prior to Nucala use; added continuation criteria for HES indication; added maximum units; medical policy formatting change. Policy notification given 2/26/2021 for effective date 4/28/2021.
Intra Articular Hyaluronan Injections for Treatment of Osteoarthritis of the Knee Added maximum units; medical policy formatting change. Policy notification given 2/26/2021 for effective date 4/28/2021.
Omalizumab (Xolair®) Added requirement to be prescribed by or in consultation with a specialist; added maximum units; medical policy formatting change. Policy notification given 2/26/2021 for effective date 4/28/2021.
Somatostatin Analogs Added requirement in initial section for Somatuline Depot for trial of or intolerance/contraindication to Sandostatin LAR Depot; adjusted initial length of authorization to 6 months for Signifor LAR; added maximum units; medical policy formatting change. Policy notification given 2/26/2021 for effective date 4/28/2021.
Tildrakizumab-asmn (Ilumya®) Addition of criteria for history of use of another biologic immunomodulator agent (or Otezla) for the same indication; PS: BSA requirement changed to 10%, added option for concomitant severe PsA; added requirement that patient has no FDA labeled contraindications, and for TB testing; added maximum units; medical policy formatting change. Policy notification given 2/26/2021 for effective date 4/28/2021.
Tocilizumab (Actemra®) Addition of criteria for history of use of another biologic immunomodulator agent for the same indication; RA: added requirement of trial of methotrexate or another conventional agent; GCA: added requirement of trial of systemic corticosteroids; PJIA: added requirement of trial of one conventional agent; SJIA: added requirement of trial with NSAIDs or another conventional agent; removed requirements for laboratory values and no active infection present; added requirements to be prescribed by or in consultation with a specialist, that patient has no FDA labeled contraindications, and for TB testing; added maximum units; medical policy formatting change. Policy notification given 2/26/2021 for effective date 4/28/2021.
Ustekinumab (Stelara®) Addition of criteria for history of use of another biologic immunomodulator agent (or Otezla) for the same indication; PS: BSA requirement changed to 10%, added option for concomitant severe PsA; PsA: added requirement for trial of one conventional agent, added option for severe active PsA or concomitant severe psoriasis; added requirements to be prescribed by or in consultation with a specialist, that patient has no FDA labeled contraindications, and for TB testing; added maximum units; medical policy formatting change. Policy notification given 2/26/2021 for effective date 4/28/2021.
Vedolizumab (Entyvio®) Addition of criteria for history of use of another biologic immunomodulator agent for the same indication; added requirement to be prescribed by or in consultation with a specialist; added requirements that the patient will not be using the requested agent in combination with another biologic immunomodulator agent, patient has no FDA labeled contraindications, and for TB testing; added maximum units; medical policy formatting change. Policy notification given 2/26/2021 for effective date 4/28/2021.