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

May 02, 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.

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.

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