Provider Alerts

Effective March 10, 2025 the Pharmacy and Therapeutics Committee has approved the following changes to the medical benefit.

1. Code J1632 – INJECTION, BREXANOLONE, 1 MG, (Zulresso): Prior authorization (PA) required. Reserved for ALL of the following:

• Age 15 years or older;
• Diagnosis of moderate to severe postpartum depression with symptom onset during the third trimester of pregnancy up to 4 weeks post delivery;
• Patient is less than or equal to 6 months postpartum; AND
• Patient is not currently pregnant.

Limited to one infusion per pregnancy. Must be prescribed by a specialist.
Other Notes: Avoid use in patients with eGFR of <15 mL/minute/1.73 m².

2. Code J3111 – INJECTION, ROMOSOZUMAB-AQQG, 1 MG, (EVENITY): Prior authorization (PA) required. Reserved for either 1 or 2:

       1)Treatment failure to bisphosphonate with calcium therapy, defined as progression of bone loss or fracture occurring while on therapy OR intolerance to 2 bisphosphonates.

2)Treatment of very high-risk patients defined as having one of the following:

• History of multiple fractures;
• Recent fracture within the past 12 months;
• Fracture or progression of bone loss while on approved osteoporosis therapy;
• Fracture while on drugs causing skeletal harm such as long-term glucocorticoids;
• Very low T-score <-3.0;
• High risk for falls or history of injurious falls;
• FRAX >30% for major osteoporosis fracture or >4.5% for hip fracture; OR
• Severe vertebral fracture (>40% loss of vertebral height).

Limited to 2 pens (1.17ml each) per 30 days and 12 total months of treatment.

Required Information for Approval: No previous history of heart attack or stroke within one year of initiating therapy.

3. Code J1756 – INJECTION, IRON SUCROSE, 1 MG, (VENOFER): No prior authorization required.
4. Codes Q0138 & Q0139 – INJECTION, FERUMOXYTOL, (FERAHEME), 1MG: No prior authorization required.
5. Code J1439 – INJECTION, FERRIC CARBOXYMALTOSE, 1 MG (INJECTAFER) & Code J1437– INJECTION, FERRIC DERISOMALTOSE, 10 MG (MONOFERRIC): Prior authorization (PA) required. Reserved for patients with one or more of the following AND has documented history of treatment failure or inability to tolerate Infed, Ferrlecit, Venofer or Feraheme:

• Absolute iron deficiency anemia with a ferritin <30μg/L or TSAT <20% with treatment failure or inability to tolerate oral iron.
• Iron deficiency anemia associated with inflammatory conditions (e.g. inflammatory bowel disease, heart failure) with a ferritin <100 μg/L or TSAT <20%.
• Chronic kidney disease with or without dialysis with ferritin < 500μg/L and TSAT <30% with treatment failure or inability to tolerate oral iron for non-dialysis patients.
• Chemotherapy-induced anemia with ferritin 30-500μg/L or TSAT <50% in patients receiving ESAs. Ferritin must not exceed 800μg/L, and TSAT must not be ≥50%.

6. Code J0896 – INJECTION, LUSPATERCEPT-AAMT, 0.25 MG (REBLOZYL): Prior authorization (PA) required. Reserved for adult patients over 18 years of age with one or more of the following:
   a) Anemia in Beta thalassemia who require regular red blood cell (RBC) transfusions
   a. With symptomatic anemia, as evidenced by pretreatment Hgb of Hgb <11 g/dL; AND
   b. A clinically documented diagnosis of beta thalassemia (β-thalassemia) or Hemoglobin E/β-thalassemia.
   i. β-thalassemia with mutation and/or multiplication of alpha globin is allowed.
   ii. Patient does not have a diagnosis of Hemoglobin S/β-thalassemia or alpha (α)-thalassemia.
   c. Requiring at least 6 red blood cell (RBC) units transfused in the previous 24 weeks and no transfusion-free period for equal to or greater than 35 days during that period.
   b)  Anemia in Very low- to intermediate-risk myelodysplastic syndromes (MDS)
   a. Who may require regular red blood cell (RBC) transfusions; AND
   b. Requiring 2 or more RBC units over 8 weeks.
   c) Anemia in Very low- to intermediate-risk myelodysplastic syndromes with ring sideroblasts (MDS-RS) or with myelodysplastic/myeloproliferative neoplasm with ring sideroblasts and thrombocytosis (MDS/MPN-RS-T)
   a. Inadequate response to or ineligible for erythropoiesis stimulating agent (ESA) therapy for 3 months; AND
   b. Requiring 2 or more RBC units over 8 weeks.
   Limited to an initial approval of up to 6 months.

7. Code J3490 (Unclassified Drugs) – IMETELSTAT (RYTELO): Reserved for adult patients over 18 years of age with the following:
   a) Anemia in Very low- to intermediate-risk myelodysplastic syndromes (MDS) with
   a. Inadequate response to or ineligible for erythropoiesis stimulating agent (ESA) therapy for 3 months; AND
   b. Requiring 4 or more RBC units over 8 weeks.

Limited to an initial approval of up to 6 months.

8. Codes J1459, J1551, J1554, J1555, J1556, J1557, J1558, J1559, J1561, J1562, J1566, J1568, J1569, J1572, J1575, J1576, J1599 – Intravenous Immunoglobulins, (Alyglo; Asceniv; Bivigam; Carimune NF; Cutaquig; Cuvitru; Flebogamma DIF; GamaSTAN; Gammagard; Gammagard S/D Less IgA; Gammaked; Gammaplex; Gamunex-C; Hizentra; Hyqvia; Octagam; Panzyga; Privigen; Xembify): Reserved for patients with one or more of the following:

• Prevention of acute humoral rejection for high-risk solid organ transplant patients, including those who are highly sensitized, have positive cross match, or have a live donor with ABO incompatibility.
• Treatment of acute humoral rejection for patients with documentation of antibody-mediated rejection (AMR) post-transplant.
• Hypogammaglobulinemia for preventing post-transplant infections for patients with documented low IgG levels (e.g. <400 mg/dL).
• Refractory BK viremia for kidney transplant patients who have persistent viral titers despite reduced immunosuppression.
• Other off-label indications supported by society guidelines.

If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website www.hpsj-mvhp.org