| Medical Drug Policy Name | Revised Criteria |
|---|---|
| Alemtuzumab (Lemtrada) | Added requirement that one of the two required trial and failure MS agents is a generic product [dimethyl fumarate (generic Tecfidera), fingolimod (generic Gilenya), glatiramer acetate (generic Copaxone), or teriflunomide (generic Aubagio)], or allow for presence of highly active MS disease activity, or previous treatment with at least 3 MS agents from different drug classes. Added requirement of some walking or functional arm/hand use within initial criteria, and added no concurrent use with two or more disease-modifying MS drugs. Added specialist requirement. Added continuation criteria to policy. Adjusted policy formatting and added reference table with drug classes of MS disease modifying agents. Updated maximum units specific to initial and continuation therapy. Policy notification given 5/2/2023 for effective date 7/1/2023. |
| Natalizumab (Tysabri) | For MS: Adjusted requirement of trial and failure of alternative MS disease-modifying therapy to one generic product [dimethyl fumarate (generic Tecfidera), fingolimod (generic Gilenya), glatiramer acetate (generic Copaxone), or teriflunomide (generic Aubagio)] or previous treatment with at least 3 MS agents from different drug classes. Added requirement of some walking or functional arm/hand use within initial criteria. Removed requirement of no concomitant use with another chronic immunosuppressant agent for clarity. For CD: Updated list of conventional agents and biologic agents for trial and failure. For both indications, added continuation criteria and removed requirement of no significant immunocompromise. Adjusted policy formatting and added reference table with drug classes of MS disease modifying agents. Policy notification given 5/2/2023 for effective date 7/1/2023. |
| Ocrelizumab (Ocrevus) | Added requirement of trial and failure of one generic product [dimethyl fumarate (generic Tecfidera), fingolimod (generic Gilenya), glatiramer acetate (generic Copaxone), or teriflunomide (generic Aubagio)], or presence of highly active MS disease activity, or previous treatment with at least 3 MS agents from different drug classes. Added specialist requirement. Added continuation criteria to policy. Adjusted policy formatting and added reference table with drug classes of MS disease modifying agents. Policy notification given 5/2/2023 for effective date 7/1/2023. |
| White Blood Cell Growth Factors | Restructured criteria for Rolvedon as a non-preferred long-acting white blood cell growth factor product with requirement of trial and failure of both Udenyca and Ziextenzo. Policy notification given 5/2/2023 for effective date 7/1/2023. |
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