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Important Updates to Pharmacy Policies – Please Review

Date: 04/28/25

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.303

Brentuximab Vedotin (Adcetris)

RT4: added criteria for new FDA-approved indication of relapsed or refractory LBCL in adult patients   – added criterion that disease is relapsed or refractory, added option that member is not a candidate for CAR T-cell therapy; per NCCN for B-cell lymphomas – added pathway for off-label use as a single agent or in combination with rituximab or nivolumab, clarified use in HIV-related B-cell lymphoma and PTLD are off-label indications.

7/1/2025

CP.PHAR.488

Apomorphine (Apokyn, Apokyn NXT, Onapgo)

RT4: added new formulations Apokyn NXT and Onapgo to policy; added generic apomorphine to policy requiring PA; for Apokyn or Apokyn NXT, added must use generic apomorphine language; revised “prescribed concurrently with an anti-Parkinson agent” to “prescribed concurrently with levodopa/carbidopa”; added rqeuirement for trial and failure of at least two anti-Parkinson agents from different therapeutic classes, unless clinically significant adverse events are experienced or all are contraindicated.  

7/1/2025

CP.PHAR.549

Sotorasib (Lumakras)

RT4: added new FDA-approved indication of CRC and removed requirement for previous use of a fluoropyrimidine- (e.g., 5-fluorouracil, capecitabine), oxaliplatin-, and irinotecan-containing chemotherapy per NCCN and as Appendix B now lists previous CRC regimens; removed colon, appendiceal, and rectal cancers from NCCN-recommended off-label uses section as these are now encompassed within the CRC section; for NCCN-recommended off-label uses, added requirements for positive KRAS G12C mutation, previous therapy, and Lumakras monotherapy use per NCCN Compendium; for ampullary adenocarcinoma, added requirement for disease progression per NCCN; for small bowel adenocarcinoma, added requirement for advanced or metastatic disease per NCCN; for pancreatic adenocarcinoma, added requirement for locally advanced, recurrent, or metastatic disease; for NSCLC, added monotherapy requirement.

7/1/2025

Ambetter’s clinical, payment, and pharmacy policies can be found on our website at AmbetterHealth.com/en/ar/provider-resources/clinical-payment-policies.html. New or amended policies are available here as well. To easily search for a policy:

  • Expand the accordions at the bottom of the page to view all available policies.
  • Use the Ctrl+F (or Command+F on Mac) function on your keyboard to search by keyword, policy number, or effective date.

New or amended policies are also available on the Arkansas Health & Wellness Provider News page. To view recent updates:

  • Visit ARHealthWellness.com.
  • Select the For Providers tab at the top of the screen.
  • Select Provider News from the drop-down menu.
  • Select the policy update you are interested in to view the details.

If you have questions, please call 1-877-617-0390 (TTY: 1-877-617-0392) or email Providers@ARHealthWellness.com.