Medical Policy Updates

Notification of Policy Revisions Effective August 1, 2021 (Posted June 1, 2021)

Policy	Revision
Abatacept (Orencia®) “Notification”	Removed criteria points regarding medication history indicating use of another biologic immunomodulator agent FDA labeled for the treatment of the same condition. Policy notification given 6/1/2021 for effective date 8/1/2021.
Certolizumab pegol (Cimzia®) “Notification”	Removed criteria points regarding medication history indicating use of another biologic immunomodulator agent FDA labeled for the treatment of the same condition. Policy notification given 6/1/2021 for effective date 8/1/2021.
Golimumab (Simponi Aria®) “Notification”	Removed criteria points regarding medication history indicating use of another biologic immunomodulator agent FDA labeled for the treatment of the same condition. Policy notification given 6/1/2021 for effective date 8/1/2021.
Guselkumab (Tremfya®) “Notification”	Removed criteria points regarding medication history indicating use of another biologic immunomodulator agent FDA labeled for the treatment of the same condition. Policy notification given 6/1/2021 for effective date 8/1/2021.
Infliximab (Remicade®) and Infliximab Biosimilars “Notification”	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. Policy notification given 6/1/2021 for effective date 8/1/2021.
Tildrakizumab-asmn (Ilumya®) “Notification”	Removed criterion point regarding medication history indicating use of another biologic immunomodulator agent FDA labeled for the treatment of the same condition. Policy notification given 6/1/2021 for effective date 8/1/2021.
Tocilizumab (Actemra®) “Notification”	Removed criteria points regarding medication history indicating use of another biologic immunomodulator agent FDA labeled for the treatment of the same condition. Policy notification given 6/1/2021 for effective date 8/1/2021.
Ustekinumab (Stelara®) “Notification”	Removed criteria points regarding medication history indicating use of another biologic immunomodulator agent FDA labeled for the treatment of the same condition. Policy notification given 6/1/2021 for effective date 8/1/2021.
Vedolizumab (Entyvio®) “Notification”	Removed criteria points regarding medication history indicating use of another biologic immunomodulator agent FDA labeled for the treatment of the same condition. Policy notification given 6/1/2021 for effective date 8/1/2021.
White Blood Cell Growth Factors “Notification”	Under “When Covered,” added specific pegfilgrastim biosimilars [e.g., Fulphila (pegfilgrastim-jmdb), Nyvepria (pegfilgrastimapgf)] 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 nonpreferred 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. Policy notification given 6/1/2021 for effective date 8/1/2021.