| Policy Name |
Revised Criteria |
| Eptinezumab-jjmr (Vyepti™) |
Added to initial criteria the requirement of trial and failure of fremanezumab (Ajovy) in addition to erenumab (Aimovig) and galcanezumab (Emgality). |
| Injectable and Healthcare Administered Oncology Drugs |
Added newly approved Fyarro to policy for treatment of locally advanced unresectable or metastatic malignant PEComa, and associated dosing to FDA label reference table. Removed Erwinaze, Rybrevant, Rylaze, and Tivdak from policy (notification of addition of these drugs extended to effective date 4/1/2022). Added other applicable HCPCS and diagnosis codes for clarity. Original medical policy criteria issued. |
| Injectable Clostridial Collagenase for Fibroproliferative Disorders |
Removed continuation criteria for Peyronie’s disease and adjusted approval to a maximum of 8 injections (8 visits) total from initiation for each plaque. |
| Trilaciclib (Cosela™) |
Added maximum units; medical policy formatting change. |
| White Blood Cell Growth Factors |
Added requirement of NCCN 2A or higher evidence rating for supporting compendia. Adjusted chemotherapy risk category definitions corresponding to use of WBC GFs for primary prophylaxis of febrile neutropenia. Added maximum units; medical policy formatting change. |
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