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Effective March 1, 2021: Pharmacy and Biopharmacy Policies

Date: 12/23/20

Superior HealthPlan has created a new policy and revised existing 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 have been created, revised or retired:

 

Policy

Applicable Products

New Policy Overview or Updated Policy Revisions

Abemaciclib (Verzenio) (CP.PHAR.355)

Ambetter

Policy includes:

  • Requests for indications not approved by the FDA are reviewed with the off-label use policy for the relevant line of business: HIM.PHAR.21 for Ambetter
  • Initial Approval Criteria:
    • Breast Cancer (must meet all):
  1. Diagnosis of breast cancer;
  2. Prescribed by or in consultation with an oncologist;
  3. Age ≥ 18 years;
  4. Disease has all of the following characteristics:
    1. HR-positive (i.e., estrogen receptor (ER) and/or progesterone receptor (PR) positive);
    2. HER2-negative;
    3. Advanced, recurrent, or metastatic;
  5. Verzenio is prescribed in one of the following ways:
    1. In combination with fulvestrant;
    2. As a single agent after disease progression on an endocrine therapy and chemotherapy (e.g., docetaxel, gemcitabine);
    3. In combination with an aromatase inhibitor (e.g., letrozole, anastrozole, exemestane), and:
    4. If male, an agent that suppresses testicular steroidogenesis (e.g., gonadotropin-releasing hormone agonists);
  6. Member has not previously experienced disease progression on a CDK 4/6 inhibitor therapy (e.g., Ibrance®, Kisqali®);
  7. Request meets one of the following:*
    1. Dose does not exceed one of the following (i or ii):
    2. For combination therapy: 300 mg per day (two 150 mg tablets per day);
    3. For monotherapy: 400 mg per day (two 200 mg tablets per day);
    4. Dose is supported by practice guidelines or peer-reviewed literature for the relevant off-label use (prescriber must submit supporting evidence).

*Prescribed regimen must be FDA-approved or recommended by NCCN

Approval duration: 6 months

  • Continued Therapy Criteria:
    • Breast Cancer (must meet all):
  1. Currently receiving medication via Centene benefit, or documentation supports that member is currently receiving Verzenio for breast cancer and has received this medication for at least 30 days;
  2. Member is responding positively to therapy;
  3. Dose is ≥ 100 mg per day;
  4. If request is for a dose increase, request meets one of the following:*
    1. New dose does not exceed one of the following:
    2. For combination therapy: 300 mg per day (two 150 mg tablets per day);
    3. For monotherapy: 400 mg per day (two 200 mg tablets per day);
    4. New dose is supported by practice guideline or peer-reviewed literature for the relevant off-label use (prescriber must submit supporting evidence).

*Prescribed regimen must be FDA-approved or recommended by NCCN
Approval duration:  12 months

Aclidinium-formoterol (Duaklir Pressair) (HIM.PA.151)

Ambetter

Policy includes:

  • Requests for indications not approved by the FDA are reviewed with the off-label use policy for the relevant line of business: HIM.PHAR.21 for Ambetter
  • Initial Approval Criteria:
    • Chronic Obstructive Pulmonary Disease (must meet all):
  1. Diagnosis of COPD;
  2. Age ≥ 18 years;
  3. Failure of Anoro® Ellipta® and Bevespi Aerosphere®, at up to maximally indicated doses unless contraindicated or clinically significant adverse effects are experienced;
  4. Dose does not exceed 2 inhalations per day (1 inhaler per 30 days).

Approval duration: 12 months

  • Continued Therapy:
    • Chronic Obstructive Pulmonary Disease (must meet all):
  1. Currently receiving medication via Centene benefit or member has previously met initial approval criteria;
  2. Member is responding positively to therapy;
  3. If request is for a dose increase, new dose does not exceed 2 inhalations per day (1 inhaler per 30 days).

Approval duration: 12 months

Acyclovir Buccal Tablet (Sitavig), Ophthalmic Ointment (Avaclyr) (CP.PMN.210)

Ambetter

Policy includes:

  • Requests for indications not approved by the FDA are reviewed with the off-label use policy for the relevant line of business: HIM.PHAR.21 for Ambetter
  • Initial Approval Criteria:
    • Herpes Labialis (must meet all):
  1. Diagnosis of recurrent herpes labialis (cold sores);
  2. Request is for Sitavig;
  3. Age ≥ 18 years;
  4. Member meets one of the following:
    1.  Failure of generic acyclovir tablets or capsules, unless contraindicated or clinically significant adverse effects are experienced;
    2. Documentation supports inability to use (i.e., inability to swallow) generic acyclovir tablets or capsules;
  5. Dose does not exceed 50 mg (single dose).
    Approval duration: 1 month (up to 2 doses)
  • Herpetic Keratitis (must meet all):
  1. Diagnosis of acute herpes keratitis (dendritic ulcers);
  2. Request is for Avaclyr;
  3. Age ≥ 2 years;
  4. Member meets one of the following:
    1. Failure of generic acyclovir tablets or capsules, unless contraindicated or clinically significant adverse effects are experienced;
    2. Documentation supports inability to use (i.e., inability to swallow) generic acyclovir tablets or capsules;
  5. Dose does not exceed 3.5 grams (1 tube every 14 days).
    Approval duration: 1 month
  • Continued Therapy:
    • Herpes Labialis (must meet all):
  1. Member meets initial approval criteria;
  2. Request is for Sitavig;
  3. Member previously responded positively to therapy;
  4. Dose does not exceed 50 mg (single dose).
    Approval duration: 1 month (up to 2 doses)
  • Herpes Keratitis (must meet all):
  1. Currently receiving medication via Centene benefit or member has previously met initial approval criteria;
  2. Request is for Avaclyr;
  3. Member previously responded positively to therapy;
  4. Dose does not exceed 3.5 grams (1 tube) every 14 days.
    Approval duration: 1 month

Betamethasone Dipropionate Spray (Sernivo) (CP.PMN.182)

Ambetter

Policy includes:

  • Requests for indications not approved by the FDA are reviewed with the off-label use policy for the relevant line of business: HIM.PHAR.21 for Ambetter
  • Initial Approval Criteria:
    • Plaque Psoriasis (must meet all):
  1. Diagnosis of PsO;
  2. Age ≥ 18 years;
  3. Failure of a medium to ultra-high potency topical corticosteroid (see Appendix B), unless contraindicated or clinically significant adverse effects are experienced;
  4. Failure of one of the following, unless clinically significant adverse effects are experienced or all are contraindicated: calcipotriene, calcitriol, or tazarotene;
  5. Dose does not exceed 120 mL every 4 weeks.
    Approval duration: 1 month
  • Continued Therapy:
    • Plaque Psoriasis (must meet all):
  1. Currently receiving medication via Centene benefit or member has previously met initial approval criteria;
  2. Member is responding positively to therapy;
  3. If request is for a dose increase, new dose does not exceed 120 mL every 4 weeks.
    Approval duration: Up to 1 month of total treatment (a single continuous course of therapy up to 4 weeks is recommended)

Bevacizumab (Avastin, Mvasi, Zirabev) (CP.PHAR.93)

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

Updates include:

  • Removed AIDS-related Kaposi sarcoma as an off label use as it is no longer NCCN supported
  • Added additional NCCN supported regimens for colorectal cancer, non-squamous non-small cell lung cancer, renal cell carcinoma, cervical cancer, and epithelial ovarian, fallopian tube, or primary peritoneal cancer
  • Added to Section IB metastatic spine tumors or brain metastases and vulvar cancer diagnoses which are supported by NCCN

Calcipotriene/Betamethasone Dipropionate Foam (Enstilar) (CP.PMN.181)

Ambetter

Policy includes:

  • Requests for indications not approved by the FDA are reviewed with the off-label use policy for the relevant line of business: HIM.PHAR.21 for Ambetter
  • Initial Approval Criteria:
    • Plaque Psoriasis (must meet all):
  1. Diagnosis of PsO;
  2. Age ≥ 12 years;
  3. Failure of a medium to ultra-high potency topical corticosteroid (see Appendix B) unless contraindicated or clinically significant adverse effects are experienced;
  4. Failure of one of the following, unless clinically significant adverse effects are experienced or all are contraindicated: calcipotriene, calcitriol, or tazarotene;
  5. Dose does not exceed 60 g every 4 days (7 canisters per month).

Approval duration: One month

  • Continued Therapy:
    • Plaque Psoriasis (must meet all):
  1. Currently receiving medication via Centene benefit or member has previously met initial approval criteria;
  2. Member is responding positively to therapy;
  3. If request is for a dose increase, new dose does not exceed 60 gm every 4 days (7 canisters per month).
    Approval duration: Up to one month of total treatment (a single continuous course of therapy up to 4 weeks is recommended)

Cholic Acid (Cholbam) (CP.PHAR.390)

Ambetter

Updates include:

  • Updated criteria to require diagnosis confirmation, allow metabolic disease specialist, and require evidence of improvement in LFTs for continued therapy
  • Shortened initial approval duration to 3 months from 6 months per package insert stating that therapy should be discontinued if insufficient response or complete biliary obstruction occurs at 3 months

Denosumab (Prolia, Xgeva) (CP.PHAR.58)

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

Updates include:

  • The MM/solid tumor common criteria line item, at risk for skeletal related event, is removed for solid tumor and for MM is replaced with receiving or initiating therapy for symptomatic disease per pivotal trials/NCCN
  • IV bisphosphonate trials are added per labels/NCCN to prostate/breast fracture prevention, MM/solid tumor (exception prostate/breast cancer), and systemic mastocytosis

Eculizumab (Soliris) (CP.PHAR.97)

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

Updates include:

  • For NMOSD: added requirement against concurrent use with rituximab, Enspryng, or Uplizna

Elagolix (Orilissa), Elagolix/Estradiol/Norethinedrone (Oriahnn) (CP.PHAR.136)

Ambetter

Updates include:

  • For endometriosis, 3-month trial within the last year and non-contraceptive progestin added to reconcile with similar policies
  • Criteria added for new FDA-approved combination product and its indication: Oriahnn for management of heavy menstrual bleeding due to uterine fibroids

Eluxadoline (Viberzi) (CP.PMN.170)

Ambetter

Policy includes:

  • Requests for indications not approved by the FDA are reviewed with the off-label use policy for the relevant line of business: HIM.PHAR.21 for Ambetter
  • Initial Approval Criteria:
    • Irritable Bowel Syndrome with Diarrhea (must meet all):
  1. Diagnosis of IBS-D;
  2. Age ≥ 18 years;
  3. Failure of an anti-diarrheal agent (e.g., loperamide) at up to maximally indicated doses, unless clinically significant adverse effects are experienced or all are contraindicated;
  4. Failure of an antispasmodic (e.g., dicyclomine) at up to maximally indicated doses, unless clinically significant adverse effects are experienced or all are contraindicated;
  5. Dose does not exceed 200 mg (2 tablets) per day.
    Approval duration: 12 months
  • Continued Therapy:
    • Irritable Bowel Syndrome with Diarrhea (must meet all):
  1. Currently receiving medication via Centene benefit or member has previously met initial approval criteria;
  2. Member is responding positively to therapy;
  3. If request is for a dose increase, new dose does not exceed 200 mg (2 tablets) per day.
    Approval duration: 12 months

Eribulin mesylate (Halaven) (CP.PHAR.318)

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

Updates include:

  • For STS per NCCN recommendations – added “advanced” designation to extremity/body wall and head/neck STS
  • Removed “progressive” and added “recurrent or stage IV” designation to retroperitoneal/intra-abdominal STS
  • Added “advanced or metastatic” designation to pleomorphic rhabdomyosarcoma
  • Added additional STS subtype options: solitary fibrous tumor and UPS; added that Halaven should be used as subsequent therapy for all STS subtypes except angiosarcoma, solitary fibrous tumor, and UPS

Esketamine (Spravato) (CP.PMN.199)

Ambetter

Updates include:

  • Criteria added for new FDA-approved indication: MDD with acute suicidality
  • For TRD indication initial review: added a time frame to the PHQ-9 score of 4 weeks to ensure assessment is current, added criteria for either no previous use of Spravato or prior positive response to ensure appropriate use, added requirement for psychiatrist prescriber and added upper limit of 75 years of age

Formulary Medications Without Specific Guidelines (HIM.PA.33)

Ambetter

Updates include:

  • Added NCCN 2B as an acceptable level of evidence for off-label
  • Added criteria for combinations products and alternative dosage forms or strengths of existing drugs
  • Added requirement for redirection to two preferred FDA-approved drugs

Goserelin Acetate (Zoladex) (CP.PHAR.171)

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

Updates include:

  • Revised notation on endometriosis to state total duration of therapy should not exceed 6 months (previously stated 12 months) per the prescribing information

Imatinib (Gleevec) (CP.PHAR.65)

Ambetter

Updates include:

  • AIDS-related KS: updated criteria to require concurrent use with antiretroviral therapy and failure of first line agents per NCCN guidelines
  • Added immunologist as a prescriber option

Infertility and Fertility Preservation (CP.PHAR.131)

Ambetter

Updates include:

  • Step therapies added to OI and ART
  • 150 unit cartridge added to Follistim-AQ
  • Exclusion added for use of policy drugs as treatment for obesity

Irinotecan Liposome (Onivyde) (CP.PHAR.304)

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

Updates include:

  • Added oncologist prescriber requirement

Lapatinib (Tykerb) (CP.PHAR.79)

Ambetter

Updates include:

  • Updated the following off-label criteria per NCCN category 2A recommendations: chordoma- added that Tykerb must be prescribed as a single agent
  • Colorectal cancer- added that disease must also be BRAF wild type

Lenalidomide (Revlimid) (CP.PHAR.71)

Ambetter

Updates include:

  • AIDS-related KS: updated criteria to require concurrent use with antiretroviral therapy and failure of first line agents per NCCN guidelines
  • Added immunologist as a prescriber option

L-glutamine (Endari) (CP.PMN.116)

Ambetter

Policy includes:

  • Requests for indications not approved by the FDA are reviewed with the off-label use policy for the relevant line of business: HIM.PHAR.21 for Ambetter
  • Initial Approval Criteria:
    • Sickle Cell Disease (must meet all):
  1. Diagnosis of sickle cell disease;
  2. Age ≥ 5 years;
  3. Failure of hydroxyurea at up to maximally tolerated doses, unless contraindicated or clinically significant adverse effects are experienced;
  4. Dose does not exceed 30 grams per day based on weight.
    Approval duration: 12 months
  • Continued Therapy
    • Sickle Cell Disease (must meet all):
  1. Currently receiving medication via Centene benefit or member has previously met initial approval criteria;
  2. Member is responding positively to therapy;
  3. If request is for a dose increase, new dose does not exceed 30 grams per day based on weight.
    Approval duration: 12 months

Migalastat (Galafold) (CP.PHAR.394)

Ambetter

Updates include:

  • Added requirement for enzyme or genetic testing to confirm Fabry disease diagnosis, consistent with the previously P&T-approved approach for Fabry disease diagnosis confirmation for Fabrazyme

Mometasone (Asmanex) (HIM.PA.01)

Ambetter

Policy includes:

  • Requests for indications not approved by the FDA are reviewed with the off-label use policy for the relevant line of business: HIM.PHAR.21 for Ambetter
  • Initial Approval Criteria
    • Asthma (must meet all):
  1. Diagnosis of asthma;
  2. One of the following:
    1. Asmanex HFA: age ≥ 5 years;
    2. Asmanex Twisthaler: age ≥ 4 years;
  3. Failure of all of the following inhaled corticosteroids at up to maximally indicated doses, unless clinically significant adverse effects are experienced or all are contraindicated:§  Arnuity® Ellipta®;
    1. Flovent®;
    2. Pulmicort Flexhaler®;
    3. QVAR Redihaler®;§  Arnuity® Ellipta®;
    4. Flovent®;
    5. Pulmicort Flexhaler®;
    6. QVAR Redihaler®;
  4. Dose does not exceed one of the following:
    1. Asmanex HFA: 800 mcg per day (2 inhalers per 30 days);
    2. Asmanex Twisthaler: 880 mcg per day (2 inhalers per 30 days).

Approval duration: 12 months

  • Continued Therapy
    • Asthma (must meet all):
  1. Currently receiving medication via Centene benefit or member has previously met initial approval criteria;
  2. Member is responding positively to therapy;
  3. If request is for a dose increase, new dose does not exceed one of the following:
    1. Asmanex HFA: 800 mcg per day (2 inhalers per 30 days);
    2. Asmanex Twisthaler: 880 mcg per day (2 inhalers per 30 days).

Approval duration: 12 months

Montelukast Oral Granules (Singulair) (HIM.PA.129)

Ambetter

Updates include:

  • Updated FDA-approved indication with revised indication for allergic rhinitis to specify that use should be reserved for patients with inadequate response to alternative therapies

Nitisinone (Nityr, Orfadin) (CP.PHAR.132)

Ambetter

Updates include:

  • Added requirement for adjunctive dietary restriction of tyrosine and phenylalanine, in line with the FDA-approved indication

OnabotulinumtoxinA (Botox) (CP.PHAR.232)

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

Updates include:

  • Added the following redirections: Xeomin and Dysport for cervical dystonia and limb spasticity, Xeomin for blepharospasm
  • Per-injection dosing limitation removed to support individualized treatment for the following indications: OAB/urinary incontinence, chronic migraine,  UE/LE, CD, primary axillary hyperhidrosis
  • CD continuation pediatric dosing is corrected to reflect 300 rather than 340 Units
  • For esophageal achalasia continuation criteria, prior toxin therapy is corrected to reflect 12 rather than 24 weeks with addition of a 24-week treatment session limitation after 2 or more sessions
  • Revised upper limb spasticity redirection for pediatric patients age 2 to 17 years old from Dysport only to both Dysport and Xeomin per Xeomin FDA labeling update

Oxymetazoline (Rhofade, Upneeq) (CP.PMN.86)

Ambetter

Policy includes:

  • Requests for indications not approved by the FDA are reviewed with the off-label use policy for the relevant line of business: HIM.PHAR.21 for Ambetter
  • Initial Approval Criteria
  • Facial Erythema Associated with Rosacea HIM – refer to HIM.PA.103
    • Acquired Blepharoptosis (must meet all):
  1. Diagnosis of acquired blepharoptosis/ptosis (e.g., aponeurotic, neurologic ptosis);
  2. Request is for Upneeq;
  3. Prescribed by or in consultation with an optometrist or ophthalmologist.
  4. Age ≥ 13 years;
  5. Member does not have congenital or mechanical ptosis;
  6. Documentation of baseline visual peripheral field test (e.g., Leicester peripheral field test [LPFT]) demonstrating visual field loss;
  7. Documentation of baseline marginal reflex distance 1 (MRD-1) ≤ 2 mm;
  8. Dose does not exceed 1 carton (30 single use containers) per affected eye per month.
    Approval duration: 12 months
  • Continued Therapy
    • Acquired Blepharoptosis (must meet all):
  1. Currently receiving medication via Centene benefit or member has previously met initial approval criteria;
  2. Reqeust is for Upneeq;
  3. Member is responding positively to therapy as evidenced by, including but not limited to, improvement in visual peripheral field test (e.g., LPFT) or MRD-1;
  4. Dose does not exceed 1 carton (30 single use containers) per affected eye per month.
    Approval duration: 12 months

Palbociclib (Ibrance) (CP.PHAR.125)

Ambetter

Updates include:

  • For breast cancer, modified to allow first-line use with fulvestrant per NCCN category 1 recommendation
  • For retroperitoneal liposarcoma, modified to allow only unresectable disease (removed metastatic and progressive options) per NCCN category 2A recommendation
  • Added coverage exclusion for use as adjuvant therapy for early stage (stage II-III) breast cancer, based on PALLAS trial results

Peginterferon Alfa-2a,b (Pegasys, PegIntron, Sylatron) (CP.PHAR.89)

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

Updates include:

  • Added inadequate response or loss of response to hydroxyurea or interferon therapy if peginterferon alfa-2b or peginterferon alfa-2a naïve for polycythemia vera
  • Added inadequate response or loss of response to hydroxyurea, anagrelide, or interferon therapy, if peginterferon alfa-2b or peginterferon alfa-2a naïve for essential thrombocytopenia
  • Added NCCN-recommended (with Category 2A or above) off-label uses: primary cutaneous CD30+ T-cell lymphoproliferative disorder, adult T-cell leukemia or lymphoma; Mycosis fungoides or Sezary syndrome

Pegvaliase-pqpz (Palynziq) (CP.PHAR.140)

Ambetter

Updates include:

  • Added requirement for current and continued use of Phe-restricted diet
  • Added requirement for a prior trial of Kuvan
  • Revised continuation criteria to reflect updated dosing recommendations in the package labeling

Plecanatide (Trulance) (CP.PMN.87)

Ambetter

Policy includes:

  • Requests for indications not approved by the FDA are reviewed with the off-label use policy for the relevant line of business: HIM.PHAR.21 for Ambetter
  • Initial Approval Criteria
    • Chronic Idiopathic Constipation (must meet all):
  1. Diagnosis of CIC;
  2. Age ≥ 18 years;
  3. Failure of one bulk forming laxative (e.g., psyllium (Metamucil®), methylcellulose (Citrucel®), calcium polycarbophil (FiberCon®)), unless clinically significant adverse effects are experienced or all are contraindicated;
  4. Failure of one stimulant laxative (e.g., bisacodyl, senna), unless clinically significant adverse effects are experienced or all are contraindicated;
  5. Failure of polyethylene glycol (MiraLax®) at up to maximally indicated doses, unless contraindicated or clinically significant adverse effects are experienced;
  6. Dose does not exceed 3 mg (1 tablet) per day.
    Approval duration: 12 months
  •  Irritable Bowel Syndrome with Constipation (must meet all):
  1. Diagnosis of IBS-C;
  2. Age ≥ 18 years;
  3. Failure of one bulk-forming laxative (e.g. psyllium (Metamucil), methylcellulose (Citrucel), calcium polycarbophil (FiberCon)), unless clinically significant adverse effects are experienced or all are contraindicated;
  4. Dose does not exceed 3 mg (1 tablet) per day.
    Approval duration: 12 months
  • Continued Therapy
    • All Indications in Section I (must meet all):
  1. Currently receiving medication via Centene benefit or member has previously met initial approval criteria;
  2. Member is responding positively to therapy;
  3. If request is for a dose increase, new dose does not exceed 3 mg (1 tablet) per day.
    Approval duration: 12 months

Ribociclib (Kisqali), Ribociclib/Letrozole (Kisqali Femara) (CP.PHAR.334)

Ambetter

Policy includes:

  • Requests for indications not approved by the FDA are reviewed with the off-label use policy for the relevant line of business: HIM.PHAR.21 for Ambetter
  • Initial Approval Criteria
    • Breast Cancer (must meet all):
  1. Diagnosis of breast cancer;
  2. Prescribed by or in consultation with an oncologist;
  3. Age ≥ 18 years;
  4. Disease has all of the following characteristics:
    1. HR-positive (i.e., estrogen receptor (ER) and/or progesterone receptor (PR) positive);
    2. HER2-negative;
    3. Advanced, recurrent, or metastatic;
    4. If request is for Kisqali, therapy is prescribed in combination with one of the following:
    5. An aromatase inhibitor (e.g., letrozole, anastrozole, exemestane);
    6. Fulvestrant;
  5. If male (off-label) and receiving an aromatase inhibitor, therapy is prescribed in combination with an agent that suppresses testicular steroidogenesis (e.g., gonadotropin-releasing hormone agonists);
  6. Member has not previously experienced disease progression on a CDK 4/6 inhibitor therapy (e.g., Verzenio®, Ibrance®);
  7. Request meets one of the following:*
    1. Dose does not exceed Kisqali 600 mg per day (3 tablets per day for 21 days) and Femara 2.5 mg per day (1 tablet per day for 28-day cycle);
    2. Dose is supported by practice guidelines or peer-reviewed literature for the relevant off-label use (prescriber must submit supporting evidence).

*Prescribed regimen must be FDA-approved or recommended by NCCN
Approval duration: 6 months

  • Continued Therapy
    • Breast Cancer (must meet all):
  1. Currently receiving medication via Centene benefit, or documentation supports that member is currently receiving Kisqali or Kisqali Femara for breast cancer and has received this medication for at least 21 days;
  2. Member is responding positively to therapy;
  3. Dose of Kisqali is ≥ 200 mg per day;
  4. If request is for a dose increase, request meets one of the following:*
    1. New dose does not exceed Kisqali 600 mg per day (3 tablets per day for 21 days) and Femara 2.5 mg per day (1 tablet per day for 28-day cycle);
    2. New dose is supported by practice guideline or peer-reviewed literature for the relevant off-label use (prescriber must submit supporting evidence).

*Prescribed regimen must be FDA-approved or recommended by NCCN
Approval duration: 12 months

Rifaximin (Xifaxan) (CP.PMN.47)

Ambetter

Updates include:

  • Deleted off-label Crohn’s disease criteria set as use is not supported by treatment guidelines

RimabotulinumtoxinB (Myobloc) (CP.PHAR.233)

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

Updates include:

  • Added the following redirections: Xeomin and Dysport for cervical dystonia, Xeomin for chronic sialorrhea
  • Updated lower age limit from 18 years to 2 years for upper limb spasticity

To review all Clinical 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.

To review all Clinical 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.