Effective December 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 December 1, 2024, at 12:00AM.
POLICY
| APPLICABLE PRODUCTS
| NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS
|
Betaine (Cystadane) (CP.PHAR.143)
| Ambetter
| Policy updates include:
- For Cystadane requests, added redirection to generic
|
Luspatercept-aamt (Reblozyl) (CP.PHAR.450)
| Ambetter
| Policy updates include:
- For myelodysplastic syndromes, revised criterion myelodysplastic syndromes with ring sideroblasts < 15% (or ring sideroblasts < 5% with SFB3B1 mutation) from “failure of erythropoiesis-stimulating agent (ESA) agent unless contraindicated or documentation of current erythropoietin > 500 mU/mL” to “one of the following: response to or ineligible for ESA therapy OR both of the following: documentation of current serum erythropoietin < 500 mU/mL AND failure of Retacrit or if Retacrit is unavailable due to shortage, member must use Epogen” to direct to our preferred ESA agents
- For myelodysplastic syndromes initial approval criteria, added “myelodysplastic syndromes that is very low, low, or intermediate-1 risk as classified by International Prognostic Scoring System - Revised (IPSS-R)” as an option under diagnosis
- For myelodysplastic syndromes initial and continued therapy criteria, added “Reblozyl is not prescribed concurrently with Rytelo.”
|
Tremelimumab-actl (imjudo) (CP.PHAR.612)
| Ambetter, Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), and CHIP
| Policy updates include:
- For unresectable hepatocellular carcinoma, revised continued therapy section to not permit re-authorization per package insert
|
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.
