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Effective October 4, 2021: Pharmacy and Biopharmacy Policies

Date: 07/30/21

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 4, 2021, at 12:00AM.

POLICY

APPLICABLE PRODUCTS

NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS

Aducanumab-avwa (Aduhelm) (CP.PHAR.468)

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

Policy updates include:

  • Updated FDA Approved Indication per updated PI to reflect that Aduhelm should be initiated in the patient population that was studied the in the clinical trials; allowed up to 325 mg of ASA

Aflibercept (Eylea) (CP.PHAR.184)

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

Policy updates include:

  • Clarified “best corrected” for visual acuity for redirection to bevacizumab

Eptinezumab (Vyepti) (CP.PHAR.489)

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

Policy updates include:

  • Revised requirement on concurrent use with other CGRP inhibitors to include oral products with Nurtec and Ubrelvy listed as additional examples

Eptinezumab (Vyepti) (HIM.PA.SP64)

Ambetter

Policy updates include:

  • Revised requirement on concurrent use with other CGRP inhibitors to include oral products with Nurtec and Ubrelvy listed as additional examples

Erenumab-aaoe (Aimovig) (CP.PHAR.128)

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

Policy updates include:

  • Revised requirement on concurrent use with other CGRP inhibitors to include oral products with Nurtec and Ubrelvy listed as additional examples

Erenumab-aaoe (Aimovig) (HIM.PA.SP65)

Ambetter

Policy updates include:

  • Revised requirement on concurrent use with other CGRP inhibitors to include oral products with Nurtec and Ubrelvy listed as additional examples

Fremanezumab-vfrm (Ajovy) (CP.PHAR.403)

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

Policy updates include:

  • Revised requirement on concurrent use with other CGRP inhibitors to include oral products with Nurtec and Ubrelvy listed as additional examples

Fremanezumab-vfrm (Ajovy) (HIM.PA.SP66)

Ambetter

Policy updates include:

  • Revised requirement on concurrent use with other CGRP inhibitors to include oral products with Nurtec and Ubrelvy listed as additional examples

Galcanezumab-gnlm (Emgality) (CP.PHAR.404)

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

Policy updates include:

  • Revised requirement on concurrent use with other CGRP inhibitors to include oral products with Nurtec and Ubrelvy listed as additional examples

Galcanezumab-gnlm (Emgality) (HIM.PA.SP67)

Ambetter

Policy updates include:

  • Revised requirement on concurrent use with other CGRP inhibitors to include oral products with Nurtec and Ubrelvy listed as additional examples

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.