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Effective January 15, 2021: Pharmacy and Biopharmacy Policies

Date: 01/06/21

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. 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

Infliximab (Remicade), Infliximab-axxq (Avsola), Infliximab-dyyb (Inflectra), and Infliximab-abda (Renflexis) (CP.PHAR.254)

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

Policy updates include:

  • For Avsola requests, applied existing redirection to Inflectra and Renflexis

Biologic DMARDs (HIM.PA.SP60)

Ambetter

Policy updates include:

  • Added Avsola and applied existing redirection to Inflectra and Renflexis

Taliglucerase Alfa (Elelyso) (CP.PHAR.157)

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

Policy updates include:

  • Updated indication with age extension to include patients 4 years and older as per FDA label

Pembrolizumab (Keytruda) (CP.PHAR.322)

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

Policy updates include:
  • DA cHL label updated from relapsed disease after 3 lines of therapy to after 1 line of therapy (adults) or 2 lines of therapy (pediatrics)
  • New NCCN pediatric cHL guideline added to reference section
  • New FDA-approved TNBC indication added

Polatuzumab Vedotin-piiq (Polivy) (CP.PHAR.433)

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

Policy updates include:

  • Added 30 mg vial size to product availability

Colonoscopy Preparation Products (HIM.PA.04)

Ambetter

Policy updates include:

  • Added new dosage form, Sutab

Nebivolol (Bystolic) (HIM.PA.131)

Ambetter

Policy updates include:

  • Revised dose optimization criteria from maximum 1 tablet to 2 tablets per day

Opioid Analgesics (HIM.PA.139)

Ambetter

Policy updates include:

  • Revised approval duration for short-acting agents from 30 days to 3 months, and for long-acting agents from 30 days to 12 months

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.