Medical Policy Updates

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Notification of Drug Policy Revisions Effective January 1, 2023 (Posted November 1, 2022)

Medical Drug Policy Name Revised Criteria
Abatacept (Orencia®) “Notification” Changed requirement for trial and failure of preferred agents for rheumatoid arthritis and psoriatic arthritis to include both an infliximab product AND Simponi Aria. Policy notification given 11/1/2022 for effective date 1/1/2023.
Betibeglogene autotemcel (Zynteglo®) “Notification” Added distribution channel restriction language to policy. Adjusted formatting and defined authorization length for clarity with no change to policy intent. Policy notification given 11/1/2022 for effective date 1/1/2023.
Interleukin-5 Antagonists “Notification” Added requirement within initial criteria for asthma indication that patient must be adherent to conventional therapies. Corrected typographical, formatting, and criteria errors within policy for CRSwNP indication with no change to policy intent. Policy notification given 11/1/2022 for effective date 1/1/2023.
Intra Articular Hyaluronan Injections for Treatment of Osteoarthritis of the Knee “Notification” Changed requirement for trial and failure of preferred agents from Synvisc or Synvisc-One AND Durolane or Gelsyn-3 to Synvisc or Synvisc-One AND Orthovisc. Policy notification given 11/1/2022 for effective date 1/1/2023.
Omalizumab (Xolair®) “Notification” Added requirement within initial criteria for asthma indication that patient must be adherent to use of a medium dose inhaled corticosteroid with combination therapy. Minor formatting adjustments made to policy. Policy notification given 11/1/2022 for effective date 1/1/2023.
Tezepelumab-ekko (Tezspire™) “Notification” Added requirement within initial criteria that patient must be adherent to use of conventional asthma control therapies. Policy notification given 11/1/2022 for effective date 1/1/2023.
Tocilizumab (Actemra®) “Notification” Changed requirement for trial and failure of preferred agents for rheumatoid arthritis to include both an infliximab product AND Simponi Aria. Policy notification given 11/1/2022 for effective date 1/1/2023.