Effective January 1, 2025: Pharmacy and Biopharmacy Policies

Date: 10/18/24

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 January 1, 2025, at 12:00AM.

POLICY	APPLICABLE PRODUCTS	NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS
Ranibizumab (Byooviz, Cimerli, Lucentis, Susvimo) (CP.PHAR.186)	Ambetter, Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), and CHIP	Policy updates include: In initial approval criteria, separated diabetic macular edema and diabetic retinopathy into a new section and clarified request is for Cimerli or Lucentis
Tocilizumab (Actemra, Tofidence, Tyenne) (CP.PHAR.263)	Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), and CHIP	Policy updates include: For COVID-19 and giant cell arteritis, added Tofidence to criteria For section V, added Tofidence dosing for giant cell arteritis
Letermovir (Prevymis) (CP.PHAR.367)	Ambetter, Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), and CHIP	Policy updates include: Added pediatric extension to include age ≥ 6 months and weight ≥ 6 kg for prophylaxis of cytomegalovirus in patients who are cytomegalovirus- seropositive recipients of an allogenic hematopoietic stem cell transplant and age ≥ 12 years and weight ≥ 40 kg for prophylaxis of cytomegalovirus in kidney transplant recipients at high risk Added newly approved dosage form (oral pellets)
Maralixibat (Livmarli) (CP.PHAR.543)	Ambetter	Policy updates include: For progressive familial intrahepatic cholestasis, updated criteria with pediatric extension from 5 years to 12 months of age and older, added criteria for “request is for oral solution 19 mg/mL strength”, and updated maximum dosing criteria in initial and continued therapy to align with prescribing information For Alagille syndrome initial and continued therapy, added criteria for “request is for oral solution 9.5 mg/mL strength” Added new 19 mg/mL strength oral solution For Appendix F, added supplemental information on different strengths Updated section V to align with prescribing information dosing
Biologic and Non-biologic DMARDs (HIM.PA.SP60)	Ambetter	Policy updates include: For Simlandi, added new prefilled syringe formulation and strengths [20 mg/0.2 mL, 40 mg/0.4 mL, 80 mg/0.8 mL] For section V, added Simlandi pediatric dose for polyarticular juvenile idiopathic arthritis [15 kg to less than 30 kg: 20 mg every other week] and pediatric dose for Crohn’s disease [17 kg to less than 40 kg: 80 mg subcutaneous on Day 1, 40 mg subcutaneous on Day 15, then 20 mg subcutaneous every other week starting on Day 29] For Tofidence, added coverage for COVID-19 and giant cell arteritis For section V, added Tofidence dosing for giant cell arteritis For Appendix M, added supplemental information for Tofidence Added HCPCS code [Q5135] for Tyenne For Taltz: added new strengths for single-dose prefilled syringe [20 mg/0.25 mL, 40 mg/0.5 mL]

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.