Effective May 1, 2025: Pharmacy and Biopharmacy Policies

Tuesday, February 18, 2025 - Tuesday, February 18, 2025

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 May 1, 2025, at 12:00AM.

POLICY	APPLICABLE PRODUCTS	NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS
Tafamidis (Vyndaqel, Vyndamax) (CP.PHAR.432)	Ambetter	Policy updates include: For initial approval criteria and continued therapy, added Attruby to list of excluded agents for concurrent use
Sacituzumab govitecan-hziy (Trodelvy) (CP.PHAR.475)	Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter	Policy updates include: Updated to include withdrawal of previously Food and Drug Administration (FDA)-approved indication for urothelial cancer and changed to off-label as the use remains National Comprehensive Cancer Network (NCCN) supported Added provider attestation criterion acknowledging FDA withdrawal Added withdrawal information in Appendix D
Delandistrogene moxeparvovec-rokl (Elevidys) (CP.PHAR.593)	Ambetter	Policy updates include: Added requirement for current documentation (within the last 90 days) of member’s body weight (in kg)

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.