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Renueve antes del 15 de diciembre para tener cobertura el 1 de enero. Mantén tu cobertura con Ambetter Health.

Renueve antes del 15 de diciembre para tener cobertura el 1 de enero. Mantén tu cobertura con Ambetter Health.

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Effective December 1, 2024: Pharmacy and Biopharmacy Policies

Fecha: 20/09/24

Superior HealthPlan has added, updated, or retired 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 December 1, 2024, at 12:00AM.

Changes in these policies reflect preauthorization requirement amendments that are less burdensome to insureds, physicians, or health care providers.

POLICYAPPLICABLE PRODUCTSNEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS
Cerliponase alfa (Brineura) (CP.PHAR.338)Ambetter

Policy updates include:

  • Updated criteria to reflect the newly Food and Drug Administration (FDA)-approved indication expansion to include symptomatic and presymptomatic patients younger than 3 years of age, including the following changes: removed any references to “late infantile” disease, replaced the age requirement with the 2.5 kg minimum weight requirement per dosing recommendations in the Prescribing Information
  • Added the Boxed Warning re: hypersensitivity reactions including anaphylaxis
Asciminib (Scemblix) (CP.PHAR.565)Ambetter

Policy updates include:

  • Added new 100 mg tablet strength
Cabotegravir, Cabotegravir-rilpivirine (Apretude, Cabenuva) (CP.PHAR.573)Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

  • For PrEP indication, added criterion to generic Truvada redirection to allow bypass if member has history of non-adherence to oral PrEP therapy.
Faricimab (Vabysmo) (CP.PHAR.581)Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

  • Added newly approved prefilled syringe formulation.
Belimumab (Benlysta) (CP.PHAR.88)Ambetter

Policy updates include:

  • Updated systemic lupus erythematosus dosing for subcutaneous to reflect expanded indication to patients 5+ years old
Non-Calcium Phosphate Binders (Auryxia, Fosrenol, Renagel, Renvela, Velphoro) (CP.PMN.04)Ambetter

Policy updates include:

  • For Velphoro, updated age to ≥ 9 years (previously adults only) to reflect pediatric extension
DPP-4 inhibitors (HIM.PA.58)Ambetter

Policy updates include:

  • Added newly approved Zituvimet XR to 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.