April (Makeup) Pharmacy Provider Notification - Ambetter
Date: 07/13/26
Ambetter from Arkansas Health & Wellness is amending or implementing new policies. Please see the table below for a list of these policies and their effective dates.
| Policy | Policy Name | Revision | Effective Date |
CP.PHAR.725 | Tiopronin Delayed-Release (Thiola EC) | 2Q 2026 annual review: no significant changes; added Venxxiva as another brand formulation of Thiola EC that would require redirection to a non-brand generic equivalent; for Continued Therapy added the same requirement for concomitant use with conventional therapies as exists in the Initial Approval section and as stated in the FDA-labeled indication; references reviewed and updated. | 9/1/2026 |
| CP.PHAR.558 | Mitapivat (Pyrukynd, Aqvesme) | Per March SDC: for beta thalassemia and Hemoglobin E/beta thalassemia, added redirection to Reblozyl for members that received ≥ 6 RBC units in the last 6 months | 9/1/2026 |
| CP.PHAR.616 | Zilucoplan (Zilbrysq) | Per March SDC, added redirection to Ultomiris. | 9/1/2026 |
| CP.PHAR.759 | Nerandomilast (Jascayd) | Per March SDC, for IPF added redirection through both generic pirfenidone and Ofev; for PPF added redirection through Ofev | 9/1/2026 |
| CP.PHAR.236 | Darbepoetin Alfa (Aranesp) | 2Q 2026 annual review: for continuation of therapy request for anemia associated with CKD, modified current hemoglobin requirement from ≤ 12 g/dL to ≤ 11.5 g/dL; for anemia associated with CKD, added requirement that requested product is not prescribed concurrently with a hypoxia-inducible factor prolyl hydroxylase (HIF PH) inhibitor; references reviewed and updated. | 9/1/2026 |
| CP.PHAR.237 | Epoetin Alfa (Epogen, Procrit), Epoetin Alfa-epbx (Retacrit) | 2Q 2026 annual review: for continuation of therapy request for anemia associated with CKD, modified current hemoglobin requirement from ≤ 12 g/dL to ≤ 11.5 g/dL; for anemia associated with CKD, added requirement that requested product is not prescribed concurrently with a hypoxia-inducible factor prolyl hydroxylase (HIF PH) inhibitor; references reviewed and updated. | 9/1/2026 |
| CP.PHAR.238 | Methoxy Polyethylene Glycol-Epoetin Beta (Mircera) | 2Q 2026 annual review: for continuation of therapy request modified current hemoglobin requirement from ≤ 12 g/dL to ≤ 11.5 g/dL; added requirement that requested product is not prescribed concurrently with a hypoxia-inducible factor prolyl hydroxylase (HIF PH) inhibitor; references reviewed and updated. | 9/1/2026 |
| CP.PHAR.316 | Cabazitaxel (Jevtana) | 2Q 2026 annual review: per NCCN compendium for off-label use in small cell/neuroendocrine prostate cancer clarified that Jevtana is prescribed in combination with carboplatin with concurrent steroid; revised initial approval duration for Medicaid/HIM from 6 to 12 months; references reviewed and updated. | 9/1/2026 |
| CP.PHAR.337 | Telotristat Ethyl (Xermelo) | 2Q 2026 annual review: added failure of an SSA for IL HIM requests per prescribing information; in continued therapy, clarified examples of positive therapy; extended initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition; references reviewed and updated. | 9/1/2026 |
| CP.PHAR.416 | Caplacizumab-yhdp (Cablivi) | 2Q 2026 annual review: for continued criteria for new treatment cycle requests, added diagnostic requirement for confirmation of relapse; references reviewed and updated. | 9/1/2026 |
| CP.PHAR.533 | Ciltacabtagene Autoleucel (Carvykti) | 2Q 2026 annual review: per NCCN added additional approval pathway after ≥ 3 prior lines of therapy that also includes one anti-CD38 antibody; references reviewed and updated. | 9/1/2026 |
| CP.PHAR.550 | Vutrisiran (Amvuttra) | 2Q 2026 annual review: for diagnosis by cardiac uptake, specified radionucleotide scan should be SPECT (Single Photon Emission Computed Exercise Tomography) per updated 2025 ACC Clinical Guidance; removed Tegsedi from criteria as agent is discontinued; for Medicaid/HIM revised initial approval duration from 6 to 12 months; references reviewed and updated. | 9/1/2026 |
| CP.PHAR.573 | Cabotegravir, Cabotegravir-Rilpivirine (Apretude, Cabenuva) | 2Q 2026 annual review: for PrEP, added requirement that Apretude is not prescribed concurrently with any other antiretroviral medications for PrEP; references reviewed and updated. | 9/1/2026 |
| CP.PHAR.582 | Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) | 2Q 2026 annual review: added Erleada and Nubeqa as additional examples of androgen receptor pathway inhibitors that would qualify to satisfy prior therapy requirements; for continuation of therapy added requirement that member continues to use a GnRH analog concurrently or has had a bilateral orchiectomy; references reviewed and updated. | 9/1/2026 |
| CP.PHAR.60 | Capecitabine (Xeloda) | 2Q 2026 annual review: updated boxed warnings for patients with complete DPD deficiency and added criterion to confirm that a homozygous or compound heterozygous DPYD variant is not present, unless immediate treatment is necessary per updated PI; for off-label indications, added appendiceal neoplasms and cancers and subtypes of head and neck cancer (nasopharynx and occult primary tumor) and removed endometrial carcinoma per NCCN; extended initial approval duration from 6 to 12 months for this maintenance medication for a chronic condition; references reviewed and updated. | 9/1/2026 |
| CP.PHAR.669 | Birch Triterpenes (Filsuvez) | For initial approval criteria and continued therapy, added “on the same target wound” to clarify Filsuvez is not used concurrently on the same wound as Zevaskyn and Vyjuvek; added no concurrent use with Zevaskyn. | 9/1/2026 |
| CP.PHAR.677 | Vadadustat (Vafseo) | 2Q 2026 annual review: for continuation of therapy request modified current hemoglobin requirement from ≤ 12 g/dL to ≤ 11.5 g/dL; added requirement that Vafseo should not be prescribed concurrently with ESAs; references reviewed and updated. | 9/1/2026 |
| CP.PHAR.689 | Olezarsen (Tryngolza) | 2Q 2026 annual review: added option to be prescribed by gastroenterologist or pancreatologist; added requirement that Tryngola is not prescribed concurrently with Redemplo to prevent duplicative therapy; references reviewed and updated. | 9/1/2026 |
| CP.PHAR.721 | Plozasiran (Redemplo) | 2Q 2026 annual review: added option to be prescribed by gastroenterologist or pancreatologist; in continued therapy, added Redemplo is not prescribed concurrently with Tryngolza; references reviewed and updated. | 9/1/2026 |
| CP.PHAR.76 | Nilotinib (Tasigna, Danziten) | 2Q 2026 annual review: added new branded product Nilceya to criteria;, generic nilotinib is now available, so clarified generic redirection by removing ‘if available’ and for Danziten and Nilceya added step therapy bypass for IL HIM per IL HB 5395; for Medicaid/HIM revised initial approval duration from 6 to 12 months; extended off-label use to other nilotinib formulations; references reviewed and updated. | 9/1/2026 |
| CP.PHAR.78 | Thalidomide (Thalomid) | 2Q 2026 annual review: for MCD, removed option as use in active idiopathic MCD without organ failure per NCCN; for MM, ENL and off-label NCCN compendium indications, extended initial approval durations from 6 months to 12 months for this maintenance medication for a chronic condition; revised continued therapy duration for aphthous stomatitis or ulcers to 6 months; references reviewed and updated. | 9/1/2026 |
| CP.PMN.193 | Hydroxyurea (Siklos, Xromi) | 2Q 2026 annual review: for oncology off-label indications, added specialist requirement for an oncologist or hematologist; references reviewed and updated. | 9/1/2026 |
| CP.PMN.209 | Solriamfetol (Sunosi) | 2Q 2026 annual review: added requirement for OSA that Sunosi is prescribed concurrently with continued use of positive airway pressure therapy; revised CPAP requirement to allow any positive airway pressure therapy (e.g., BiPAP); for continued therapy added improvement in reported daytime wakefulness as an example of positive response to therapy; references reviewed and updated. | 9/1/2026 |
| CP.PMN.35 | Armodafinil (Nuvigil) | 2Q 2026 annual review: added requirement for OSA that armodafinil (Nuvigil) is prescribed concurrently with continued use of positive airway pressure therapy; revised CPAP requirement to allow any positive airway pressure therapy (e.g., BiPAP); references reviewed and updated. | 9/1/2026 |
| CP.PMN.39 | Modafinil (Provigil) | 2Q 2026 annual review: added requirement for OSA that modafinil (Provigil) is prescribed concurrently with continued use of positive airway pressure therapy; revised CPAP requirement to allow any positive airway pressure therapy (e.g., BiPAP); references reviewed and updated. | 9/1/2026 |
| CP.PMN.42 | Sodium Oxybate (Xyrem, Lumryz) and Calcium, Magnesium, Potassium, and Sodium Oxybate (Xywav) | 2Q 2026 annual review: for continued therapy added requirement for brand Xyrem requests, member must use sodium oxybate (generic Xyrem); references reviewed and updated. | 9/1/2026 |