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Effective August 1, 2022: Pharmacy and Biopharmacy Policies

Fecha: 26/07/22

Superior HealthPlan has updated 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 August 1, 2022 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

Brolucizumab (Beovu) (CP.PHAR.445)

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

Policy updates include:

  • Criteria added for new FDA approved indication of DME

Dabrafenib (Tafinlar) (CP.PHAR.239)

Ambetter

Policy updates include:

  • Revised criteria to include new FDA-approved indication of BRAF V600E mutation-positive solid tumors

Ivosidenib (Tibsovo) (CP.PHAR.137)

Ambetter

Policy updates include:

  • Revised criteria per updated FDA approved indication to include combination therapy with azacitidine or monotherapy for treatment of AML

Risankizumab-rzaa (Skyrizi) (CP.PHAR.426)

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

Policy updates include:

  • Updated policy with Crohn’s disease indication

Risdiplam (Evrysdi) (CP.PHAR.477)

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

Policy updates include:

  • Updated criteria with new pediatric expansion indication for pre-symptomatic infants < 2 months old

Rituximab (Rituxan), Rituximab-arrx (Riabni), Rituximab-pvvr (Ruxience), Rituximab-abbs (Truxima), RituximabHyaluronidase (Rituxan Hycela) (CP.PHAR.260)

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

Policy updates include:

  • For Riabni, updated FDA approved indications to include RA per updated prescribing information

Trametinib (Mekinist) (CP.PHAR.240)

Ambetter

Policy updates include:

  • Revised criteria to include new FDA-approved indication of BRAF V600E mutation-positive solid tumors

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.