Notification of Policy Revisions Effective July 1, 2022 (Posted May 2, 2022)

Criteria Name	Criteria Update
Xolair	Criteria change: Updated step therapy requirement through second generation H1 antihistamine and included maximum dosing for chronic idiopathic urticaria. Policy notification given 5/2/2022for effective date 7/1/2022.
Somatostatin Analogs	Criteria change: Added decreased severity and frequency of diarrhea and/or flushing symptoms as an objective marker for improvement in continuation criteria. For Signifor LAR: Added documentation of approved testing for Cushing’s diagnosis in initial and continuation criteria. Added requirement to be managed by or in consultation with a specialist (e.g., endocrinologist) in initial and continuation criteria. Updated required trial and failure agents. Updated documentation of approved testing for acromegaly diagnosis in initial and continuation criteria. Policy notification given 5/2/2022 for effective date 7/1/2022.