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. |