IN THIS ISSUE

1 1 IN THIS ISSUE Biosimilar Preferred Product Established for Rituximab .. 4 Guidelines Established for Avalglucosidase alfa-ngpt (Nexviazyme) .. 4 Biosimilar Preferred Products Established for Pegfilgrastim .. 5 Guidelines Established for Eculizumab (Soliris) .. 5 Coverage Guidelines Revised for Brentuximab Vedotin (Adcetris) .. 5 Coverage Guidelines Revised for Parathyroid Hormone (Natpara) .. 7 Policy Established for Anifrolumab-fnia (Saphnelo) .. 8 New Criteria for Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors .. 8 Established New Criteria for Eustachian Tube Balloon Dilation .. 9 Revised and Established New Criteria for Pain Management of Peripheral Nerves by Injection .. 10 Medicare Advantage .. 12 Biosimilar Preferred Product Established for Rituximab .. 12 Biosimilar Preferred Products Established for Pegfilgrastim .. 12 Guidelines Established for Eculizumab (Soliris).

2 13 Guidelines Established for Avalglucosidase alfa-ngpt (Nexviazyme) .. 13 Coverage Guidelines Revised for Brentuximab Vedotin (Adcetris) .. 13 Coverage Guidelines Revised for Parathyroid Hormone (Natpara) .. 15 Policy Established for Anifrolumab-fnia (Saphnelo) .. 16 January 2022 2 Policy Title Anticipated ISSUE Date 30 Day Notification Information I-211 - Givosiran (Givlaari) 3/7/2022 This policy is up for annual review. No changes in coverage are indicated at this time. Minor language revisions were made to this policy. Policy is set to publish on March 7, 2022. I-214 - Luspatercept (Reblozyl) 3/7/2022 This policy is up for annual review. No changes in coverage are indicated at this time. Minor language revisions were made to this policy. Policy will publish on March 7, 2022. I-3 - Allergy Immunotherapy 3/7/2022 This policy is up for annual review. No changes in coverage are indicated at this time.

3 Policy will publish on March 7, 2022. I-56 - Hydroxyprogesterone Caproate Injection as a Tech 3/7/2022 This policy is up for annual review. No changes to coverage are indicated at this time. The policy has been updated with the most recent position statements. The policy will publish on March 7, 2022. S-180 - Recombinant and Autologous Platelet-Derived Gro 3/7/2022 Annual review. No change in coverage. Y-16 - Chronic Wound Management 3/7/2022 Policy up for annual review. No change in coverage. Denial statement and language updates. S-204 - Endoscopic Radiofrequency Ablation/Cryotherapy 3/7/2022 This is the annual review of medical policy S-204. The language, coding, and denial statement were updated. The policy will publish on March 7, 2022 X-21 - Mammography 3/7/2022 This is the annual review of X-21. Language and operational guidelines were updated. The policy will publish on March 7, 2022.

4 I-245 - Anifrolumab-fnia (Saphnelo) 3/7/2022 This is a new policy for new to market therapy. This policy is being created to establish criteria for anifroluman-fnia (Saphnelo). Policy will publish March 7, 2022. I-220 - Teprotumumab-trbw (Tepezza) 3/7/2022 This policy is up for annual review. Initial authorization period has been defined as 1 course of therapy. Coding was revised to add the diagnosis code Minor language revisions were made to this policy. Policy will publish on March 7, 2022 L-10 - Selected Tests for Rheumatic Diseases 3/7/2022 This is the annual review of L-10. Language and coding updates have been made. The policy will publish on March 7, 2022. L-102 - Drug Testing in Pain Management and Substance A 1/31/2022 The coding, criteria, operational guidelines, and language have been updated on the medical policy. The policy will publish on January 31, 2022. S-74 - Suction Assisted Lipectomy (SAL) 3/7/2022 Annual review.

5 Coverage criteria updated. Dx code E65 added to policy. S-179 - Treatment of Abnormal Uterine Bleeding and Fibroids 3/7/2022 Annual review. Updated criteria. Addition of coverage for transcervical ultrasound-guided radiofrequency ablation. Update to title and description. 3 Policy Title Anticipated ISSUE Date 30 Day Notification Information I-136 - Brentuximab Vedotin (Adcetris ) 5/1/2022 This policy is up for annual review. Policy criteria and coding have been revised based on NCCN recommended updates. This policy will publish 5/1/2022 I-164 - Parathyroid Hormone (Natpara ) 5/2/2022 This is scheduled for annual review. Criteria for reauthorization is added. Policy is scheduled to publish 5/2/2022. I-228 - Lurbinectedin (Zepzelca) 3/7/2022 This policy is scheduled for annual review. Policy was updated to include standardized NCCN language and removal of diagnosis code. Policy is set to publish on March 7, 2022.

6 S-137 - Radiofrequency Ablation of Miscellaneous Solid 5/2/2022 This is the annual review of S-137. The title has been changed. Cryosurgical ablation has been added to the policy. The criteria have been revised. The coding, operational guidelines, and language have been updated. medical policy S-158 has been combined with S-137. The policy will publish on May 2, 2022. S-262 - Eustachian Tube Balloon Dilatation 5/2/2022 This policy is scheduled for annual review. New criteria have been established. Language and coding have been updated. Policy will publish on May 2, 2022. Z-52 - Pain Management of Peripheral Nerves by Injectio 5/2/2022 This is the annual review of medical policy Z-52. The language and coding have been updated on the policy. New criteria for peripheral nerve blocks, trigger point injections, and occipital nerve blocks have been added to the policy. Z-67 - Experimental/Investigational Services 5/2/2022 Two procedure codes are being relocated to S-137.

7 Policy will publish on May 2, 2022. I-146 - Monoclonal Antibodies for the Treatment of Eosinophilic Conditions 3/7/2022 This policy is being revised. A new indication was added for Nucala with corresponding diagnosis codes. The policy will publish March 7, 2022. I-130 - Eculizumab (Soliris) and Ravulizumab (Ultomiris) 3/7/2022 This policy is up for annual review. A new therapy to market is being added to policy criteria. This policy will publish March 7, 2022. I-58 - Alglucosidase alfa (Lumizyme) 3/7/2022 This policy is up for annual review. A new therapy to market is being added to policy criteria. This policy will publish March 7, 2022. S-158 - Cryosurgical Ablation and Radiofrequency Ablation of Renal Tumors 5/2/2022 This policy will be archived as it is being combined with S-137. The policy will be archived on May 2, 2022. 4 Biosimilar Preferred Product Established for Rituximab highmark blue shield has established preferred product for rituximab.

8 The preferred product for rheumatoid arthritis (RA) indications is rituximab-pvvr (Ruxience) when the clinical criteria within the policy are met. This revised medical Policy will apply to professional providers and facility claims. The effective date is April 1, 2022. Place of Service: Outpatient Please refer to medical Policy I-38, Rituximab (Rituxan), Rituximab Biosimilars, and Rituximab and Hyaluronidase Human (Rituxan Hycela), for additional information. Guidelines Established for Avalglucosidase alfa-ngpt (Nexviazyme) highmark blue shield has established new guidelines for Avalglucosidase alfa-ngpt (Nexviazyme). This revised medical Policy will apply to professional providers and facility claims. The effective date is March 7, 2022. Place of Service: Outpatient Please refer to medical Policy I-58, Alglucosidase alfa (Lumizyme), for additional information. 5 Biosimilar Preferred Products Established for Pegfilgrastim highmark blue shield has established preferred products for granulocyte colony stimulating factors (G-CSFs) pegfilgrastim.

9 The preferred products are for oncologic indications when initiating therapy and are as follows: Pegfilgrastim (Neulasta) Pegfilgrastim-jmdb (Fulphila) Pegfilgrastim-bmez (Ziextenzo) This revised medical Policy will apply to professional providers and facility claims. The effective date is April 1, 2022. Please refer to medical Policy I-88, Granulocyte Colony-Stimulating Factors, for additional information. Guidelines Established for Eculizumab (Soliris) highmark blue shield has established new guidelines for Eculizumab (Soliris). This revised medical Policy will apply to professional providers and facility claims. The effective date is March 7, 2022. Place of Service: Outpatient Please refer to medical Policy I-130, Eculizumab (Soliris) and Ravulizumab-cwvz (Ultomiris), for additional information. Coverage Guidelines Revised for Brentuximab Vedotin (Adcetris) highmark blue shield has revised criteria for Brentuxiab Vedotin (Adcetris).

10 The following indication and criteria have been added to the policy: Pediatric Hodgkin Lymphoma Re-induction therapy or subsequent therapy (if not previously used) for relapsed or refractory disease as a consideration in individuals heavily pretreated (with platinum or anthracycline-based chemotherapy) or if a decrease in cardiac function observed, in combination with: o Bendamustine; or o Nivolumab; or o Gemcitabine; or Re-introduction therapy in combination with ISRT for relapsed or refractory disease (only in highly favorable individuals**) in individuals heavily pretreated (with platinum or anthracycline based chemotherapy) or if a decrease in cardiac function observed, in combination with: o Bendamustine or o Nuvolumab; or o Gemcitabine; or Maintenance therapy following high-dose therapy and autologous stem cell rescue (HDT/ASCR) for relapsed or refractory disease for select high-risk individuals ** 6 The following indications have been updated to include the following: Primary Cutaneous Lymphomas-Mycosis Fungoides (MF)/Sezary Syndrome (SS) Preferred systemic therapy as single agent primary treatment for; o Stage IB-IIA MF with a higher skin disease burden (eg, predominantly plaque disease) and B1 blood involvement, with or without skin-directed therapy; or o Stage IVA1 or IVA2 Sezary syndrome; or o Stage IVA2 non-Sezary or stage IVB visceral disease (solid organ), with or without radiation therapy for local control.