Medical Policy Updates

Medical Policy Update for August 1, 2021

Medical Guidelines Reason for Update
Abatacept (Orencia®) Removed criteria points regarding medication history indicating use of another biologic immunomodulator agent FDA labeled for the treatment of the same condition.
Certolizumab pegol (Cimzia®) Removed criteria points regarding medication history indicating use of another biologic immunomodulator agent FDA labeled for the treatment of the same condition.
Golimumab (Simponi Aria®) Removed criteria points regarding medication history indicating use of another biologic immunomodulator agent FDA labeled for the treatment of the same condition.
Guselkumab (Tremfya®) Removed criteria points regarding medication history indicating use of another biologic immunomodulator agent FDA labeled for the treatment of the same condition.
Infliximab (Remicade®) and Infliximab Biosimilars Changed requirement for trial and failure of preferred agents to include three agents: Remicade, Avsola, and Inflectra; removed criteria points regarding medication history indicating use of another biologic immunomodulator agent FDA labeled for the treatment of the same condition; removed criterion regarding maximum units, added criterion for quantity (dose) not to exceed maximum FDA labeled or compendia supported dosing for covered indications.
Interleukin-5 Antagonists Removed hypereosinophilic syndrome exclusion from eosinophilic asthma initial criteria.
Romiplostim (NPlate®) Reformatted age and diagnosis criteria for clarity, no change to policy intent.
Tildrakizumab-asmn (Ilumya®) Removed criterion point regarding medication history indicating use of another biologic immunomodulator agent FDA labeled for the treatment of the same condition.
Tocilizumab (Actemra®) Removed criteria points regarding medication history indicating use of another biologic immunomodulator agent FDA labeled for the treatment of the same condition.
Treatment of Hereditary Angioedema Added requirement of no treatment with more than one anti-HAE medication used for the same acute or preventative treatment of HAE attacks as the requested product, for clarity with no change to policy intent.
Ustekinumab (Stelara®) Removed criteria points regarding medication history indicating use of another biologic immunomodulator agent FDA labeled for the treatment of the same condition.
Vedolizumab (Entyvio®) Removed criteria points regarding medication history indicating use of another biologic immunomodulator agent FDA labeled for the treatment of the same condition.
White Blood Cell Growth Factors Under “When Covered,” added specific pegfilgrastim biosimilars [e.g., Fulphila (pegfilgrastim-jmdb), Nyvepria (pegfilgrastim- apgf)] as non-preferred along with Neulasta (pegfilgrastim), and added the following two pegfilgrastim biosimilars as preferred: Udenyca (pegfilgrastim-cbqv) AND Ziextenzo (pegfilgrastim-bmez). Added specific filgrastim biosimilars [e.g., Granix (tbo-filgrastim)] as non- preferred along with Neupogen (filgrastim), and added the following two filgrastim biosimilars as preferred: Nivestym (filgrastim-aafi) AND Zarxio (filgrastim-sndz). Blue Cross NC Pharmacy and Therapeutics Committee 1/5/2021. Reference added. Blue Cross NC Pharmacy and Therapeutics Committee 6/29/2021.