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Effective October 1, 2021: Pharmacy and Biopharmacy Policies

Date: 09/21/21

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 October 1, 2021 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

Enfortumab Vedotin-ejfv (Padcev) (CP.PHAR.455)

Ambetter

Policy updates include:

  • Added additional urothelial cancer indication in patients ineligible for cisplatin-containing chemotherapy and have previously received one or more prior lines of therapy

GLP-1 receptor agonists (HIM.PA.53)

Ambetter

Policy updates include:

  • Updated indication and age limits down to 10 years of age for Bydureon and Bydureon BCise per updated prescribing information

Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists (CP.PMN.183)

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

Policy updates include:

·        Added criteria for the newly FDA-approved indication of treatment and reduction of risk of recurrence for pediatric VTEs

Lenvatinib (Lenvima) (CP.PHAR.138)

Ambetter

Policy updates include:

  • Criteria added for new FDA approved indication: RCC in combination with pembrolizumab

Pembrolizumab (Keytruda) (CP.PHAR.322)

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

Policy updates include:

  • Criteria added for new FDA approved indication: RCC in combination with lenvatinib

Relugolix (Orgovyx), relugolix-estradiol-norethindrone (Myfembree) (CP.PHAR.529)

Ambetter

Policy updates include:

  • Criteria added following prior clinical guidance for new FDA-approved combination product and its indication: Myfembree for management of heavy menstrual bleeding due to uterine fibroids

SGLT2 inhibitors (HIM.PA.91)

Ambetter

Policy updates include:

  • Due to the FDA approval of Jardiance for HFrEF, added that request is for either Farxiga or Jardiance for HF criteria

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.