News
Effective January 18, 2021: Pharmacy and Biopharmacy Policies
Date:
11/19/20
Superior HealthPlan has introduced new or revised pharmacy and/or 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 revised or added:
Policy
| Applicable Products
| New Policy Overview or Updated Policy Revisions
|
|---|
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
|
OnabotulinumtoxinA (Botox) (CP.PHAR.232)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Updates include:- Updated FDA approved indication for spasticity which now includes cerebral palsy for lower limb spasticity in pediatric patients
- Added the following redirections: Xeomin and Dysport for cervical dystonia and limb spasticity, Xeomin for blepharospasm
- For chronic migraine, clarified requirement for use of two oral migraine preventative therapies that are from different therapeutic classes
|
Insulin Degludec (Tresiba), Insulin Glargine (Semglee) (HIM.PA.09)
| Ambetter
| Updates include:
- Semglee added to policy
- 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, Diabetes Mellitus (must meet all):
- Diagnosis of type 1 or type 2 diabetes mellitus;
- Age ≥ 1 year;
- Failure of Basaglar® and Levemir®, unless contraindicated or clinically significant adverse effects are experienced.
- Approval duration: 12 months
- Continued Therapy, Diabetes Mellitus (must meet all):
- Currently receiving medication via Centene benefit or member has previously met initial approval criteria;
- Member is responding positively to therapy.
- Approval duration: 12 months
|
To review all pharmacy policies, please visit Superior’s Clinical 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.
