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Effective October 1, 2024: Pharmacy and Biopharmacy Policies

Date: 09/18/24

Superior HealthPlan has added, updated, or retired certain pharmacy and biopharmacy policies to ensure medical necessity review criteria is current and appropriate for members and the scope of services provided. As a result, the following policies are effective on October 1, 2024, at 12:00AM.

Changes in these policies reflect preauthorization requirement amendments that are less burdensome to insureds, physicians, or health care providers.

POLICY

APPLICABLE PRODUCTS

NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS

Cerliponase alfa (Brineura) (CP.PHAR.338)

Ambetter

Policy updates include:

  • Updated criteria to reflect the newly Food and Drug Administration (FDA)-approved indication expansion to include symptomatic and presymptomatic patients younger than 3 years of age, including the following changes: removed any references to “late infantile” disease, replaced the age requirement with the 2.5 kg minimum weight requirement per dosing recommendations in the Prescribing Information
  • Added the Boxed Warning re: hypersensitivity reactions including anaphylaxis

Asciminib (Scemblix) (CP.PHAR.565)

Ambetter

Policy updates include:

  • Added new 100 mg tablet strength

Cabotegravir, Cabotegravir-rilpivirine (Apretude, Cabenuva) (CP.PHAR.573)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

  • For PrEP indication, added criterion to generic Truvada redirection to allow bypass if member has history of non-adherence to oral PrEP therapy.

Faricimab (Vabysmo) (CP.PHAR.581)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

  • Added newly approved prefilled syringe formulation.

Belimumab (Benlysta) (CP.PHAR.88)

Ambetter

Policy updates include:

  • Updated systemic lupus erythematosus dosing for subcutaneous to reflect expanded indication to patients 5+ years old

Non-Calcium Phosphate Binders (Auryxia, Fosrenol, Renagel, Renvela, Velphoro) (CP.PMN.04)

Ambetter

Policy updates include:

  • For Velphoro, updated age to ≥ 9 years (previously adults only) to reflect pediatric extension

DPP-4 inhibitors (HIM.PA.58)

Ambetter

Policy updates include:

  • Added newly approved Zituvimet XR to criteria

To review all policies, please visit Superior’s Clinical, Payment & Pharmacy Policies webpage.

Prior to updates, pharmacy and biopharmacy clinical policies are reviewed and approved by the Pharmacy and Therapeutics (P&T) Committee.

For questions or additional information, please contact Superior’s Pharmacy Department at 1-800-218-7453, ext. 22272.