| Medical Drug Policy Name | Revised Criteria |
|---|---|
| Axatilimab-csfr (Niktimvo™) “Notification” (PDF) | Added requirement for trial and failure of belumosudil (Rezurock). Policy notification given 8/1/2025 for effective date 10/1/2025. |
| Omalizumab (Xolair®) “Notification” (PDF) | For CRSwNP indication continuation criteria, added required medical record documentation for having been on and adherent to an over-the-counter intranasal steroid since starting Xolair therapy. Policy notification given 8/1/2025 for effective date 10/1/2025. |
| Patisiran (Onpattro®) “Notification” (PDF) | For hATTR-PN indication, added required trial and failure of eplontersen (Wainua) or diagnosis of hATTR with a mixed phenotype (exhibiting both polyneuropathy and cardiomyopathy). Adjusted list of TTR-directed therapies not to be used in combination and added geneticist to specialist list for clarity. Other minor adjustments made throughout policy for clarity with no change to policy intent. Policy notification given 8/1/2025 for effective date 10/1/2025. |
| Vutrisiran (Amvuttra®) “Notification” (PDF) | For hATTR-PN indication, added required trial and failure of eplontersen (Wainua) or diagnosis of hATTR with a mixed phenotype (exhibiting both polyneuropathy and cardiomyopathy). Adjusted maximum units to more closely align with FDA label. Policy notification given 8/1/2025 for effective date 10/1/2025. |
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