Medical Policy Updates

Notification of Drug Policy Revisions Effective October 1, 2022 (Posted August 4, 2022)

Policy Name	Revised Criteria
Botulinum Toxin Injection “Notification”	Adjusted duration of approval in initial and continuation sections to 48 weeks, and initial duration of approval for migraine to 24 weeks. Policy notification given 8/4/2022 for effective date 10/1/2022.
Immunoglobulin Therapy “Notification”	Added requirement of trial and failure of an IVIG product prior to use of a SCIG product unless other criteria are met. Added requirement of trial and failure of two preferred IVIG products prior to use of non-preferred IVIG products unless other criteria are met. Added requirement of trial and failure of Hizentra and Xembify prior to use of non-preferred SCIG products (Cutaquig, Cuvitru), and trial and failure of one preferred IVIG product prior to use of HyQvia unless other criteria are met. Added continuation criteria. Policy notification given 8/4/2022 for effective date 10/1/2022.
Injectable and Healthcare Administered Oncology Drugs “Notification”	Removed Herceptin Hylecta and Rituxan Hycela from policy and added to a separate individual policy (Preferred Injectable Oncology Program). Policy notification given 8/4/2022 for effective date 10/1/2022.
Patisiran (Onpattro) “Notification”	Added requirement within initial and continuation sections that Onpattro will not be used in combination with Amvuttra or Tegsedi. Policy notification given 8/4/2022 for effective date 10/1/2022.
Preferred Injectable Oncology Program “Notification”	Added Herceptin Hylecta to policy as a non-preferred product with same criteria as Herceptin. Added Rituxan Hycela to policy as a non-preferred product with same criteria as Rituxan. Policy notification given 8/4/2022 for effective date 10/1/2022.