Notification of Drug Policy Revisions Effective April 1, 2024

Medical Drug Policy Name	Revised Criteria
Preferred Injectable Oncology Program Notification (PDF)	Changed requirement for trial and failure of preferred trastuzumab biosimilar products to include Kanjinti and Trazimera; adjusted non-preferred trastuzumab biosimilar products to include Herzuma, Ogivri, and Ontruzant. Added Ogivri (Q5114) to restricted products; removed Trazimera (Q5116) from restricted products (now unrestricted). Policy notification given 1/10/2024 for effective date 4/1/2024.
White Blood Cell Growth Factors Notification (PDF)	Changed requirement for trial and failure of preferred pegfilgrastim biosimilar products to include Fulphila and Nyvepria; adjusted non-preferred pegfilgrastim biosimilar products to include Fylnetra, Stimufend, Udenyca/Udenyca Onbody and Ziextenzo. Added Udenyca/Udenyca Onbody (pegfilgrastim-cbqv) and Ziextenzo (pegfilgrastim-bmez) to restricted products; removed Fulphila (pegfilgrastim-jmdb) and Nyvepria (pegfilgrastim-apgf) from restricted products (now unrestricted). Added new to market Udenyca formulation, Udenyca Onbody (pegfilgrastim-cbqv), to policy as non-preferred with same criteria as Neulasta OnPro. Policy notification given 1/10/2024 for effective date 4/1/2024.

Medical Drug Policy Name

Revised Criteria

Preferred Injectable Oncology Program Notification (PDF)

Changed requirement for trial and failure of preferred trastuzumab biosimilar products to include Kanjinti and Trazimera; adjusted non-preferred trastuzumab biosimilar products to include Herzuma, Ogivri, and Ontruzant. Added Ogivri (Q5114) to restricted products; removed Trazimera (Q5116) from restricted products (now unrestricted). Policy notification given 1/10/2024 for effective date 4/1/2024.

White Blood Cell Growth Factors Notification (PDF)

Changed requirement for trial and failure of preferred pegfilgrastim biosimilar products to include Fulphila and Nyvepria; adjusted non-preferred pegfilgrastim biosimilar products to include Fylnetra, Stimufend, Udenyca/Udenyca Onbody and Ziextenzo. Added Udenyca/Udenyca Onbody (pegfilgrastim-cbqv) and Ziextenzo (pegfilgrastim-bmez) to restricted products; removed Fulphila (pegfilgrastim-jmdb) and Nyvepria (pegfilgrastim-apgf) from restricted products (now unrestricted). Added new to market Udenyca formulation, Udenyca Onbody (pegfilgrastim-cbqv), to policy as non-preferred with same criteria as Neulasta OnPro. Policy notification given 1/10/2024 for effective date 4/1/2024.

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