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Effective November 17, 2020: Pharmacy and Biopharmacy Policies

Fecha: 21/09/20

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:

  • Abiraterone (Zytiga, Yonsa) (CP.PHAR.84)
  • Aducanumab (CP.PHAR.468)
  • Alemtuzumab (Lemtrada) (CP.PHAR.243)
  • Amisulpride (Barhemsys) (CP.PMN.236)
  • Anti-inhibitor Coagulant Complex (Feiba) (CP.PHAR.217)
  • Apomorphine (Apokyn) (CP.PCH.14)
  • Apomorphine (Apokyn) (CP.PHAR.488)
  • Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada, Aristada Initio) (CP.PHAR.290)
  • Avatrombopag (Doptelet) (CP.PHAR.130)
  • Belantamab Mafodotin (CP.PHAR.469)
  • Belimumab (Benlysta) (CP.PHAR.88)
  • Bempedoic acid (Nexletol), bempedoic acid-ezetimibe (Nexlizet) (CP.PMN.237)
  • Berotralstat (CP.PHAR.485)
  • Biologic DMARDs (HIM.PA.SP60)
  • Brentuximab (Adcetris) (CP.PHAR.303)
  • Brivaracetam (Briviact) (CP.PCH.26)
  • Brivaracetam (Briviact) (HIM.PA.07)
  • Buprenorphine Injection (Brixadi) (CP.PHAR.498)
  • Bupropion-naltrexone (Contrave) (CP.PCH.12)
  • Calcifediol (Rayaldee) (CP.PMN.76)
  • Capmatinib (Tabrecta) (CP.PHAR.494)
  • Carbidopa-Levodopa ER Capsules (Rytary) (CP.PMN.238)
  • Casimersen (CP.PHAR.470)
  • Cedazuridine/Decitabine (ASTX-727) (CP.PHAR.479)
  • Chenodiol (Chenodal) (CP.PMN.239)
  • Ciclesonide (Alvesco) (HIM.PA.65)
  • Cladribine (Mavenclad) (CP.PHAR.422)
  • Collagenase Clostridium Histolyticum (Xiaflex) (CP.PHAR.82)
  • Compounded Medications (CP.PCH.27)
  • Corticotropin (H.P. Acthar) (CP.PHAR.168)
  • Cytomegalovirus Immune Globulin (CytoGam) (CP.PHAR.277)
  • Daclatasvir (Daklinza) (CP.PCH.15)
  • Daclatasvir (Daklinza) (HIM.PA.SP27)
  • Daptomycin (Cubicin, Cubicin RF) (CP.PHAR.351)
  • Darbepoetin Alfa (Aranesp) (CP.PHAR.236)
  • Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Viekira Pak) (HIM.PA.SP61)
  • Deferasirox (Exjade, Jadenu) (CP.PHAR.145)
  • Deutetrabenazine (Austedo) (CP.PHAR.341)
  • Diclofenac (Cambia, Flector, Pennsaid, Solaraze, Zipsor, Zorvolex) (CP.PCH.28)
  • Dimethyl fumarate (Tecfidera), diroximel fumarate (Vumerity) (CP.PHAR.249)
  • Dornase alfa (Pulmozyme) (CP.PHAR.212)
  • Dupilumab (Dupixent) (CP.PHAR.336)
  • Elbasvir/Grazoprevir (Zepatier) (CP.PCH.16)
  • Elbasvir/Grazoprevir (Zepatier) (HIM.PA.SP62)
  • Eltrombopag (Promacta) (CP.PHAR.180)
  • Emicizumab-kxwh (Hemlibra) (CP.PHAR.370)
  • Emtricitabine/Tenofovir Alafenamide (Descovy) (CP.PMN.235)
  • Epoetin Alfa (Epogen, Procrit), Epoetin Alfa-epbx (Retacrit) (CP.PHAR.237)
  • Eptinezumab (Vyepti) (CP.PCH.29)
  • Eptinezumab (Vyepti) (CP.PHAR.489)
  • Esketamine (Spravato) (CP.PMN.199)
  • Etelcalcetide (Parsabiv) (CP.PHAR.379)
  • Factor IX Human Recombinant (CP.PHAR.218)
  • Factor VIII (CP.PHAR.215)
  • Factor VIII-von Willebrand (Alphanate, Humate-P, Vonvendi, Wilate) (CP.PHAR.216)
  • Factor XIII Human (Corifact) (CP.PHAR.221)
  • Factor XIIIa Recombinant (Tretten) (CP.PHAR.222)
  • Fedratinib (Inrebic) (CP.PHAR.442)
  • Fenfluramine (Fintepla) (CP.PMN.246)
  • Filgrastim (Neupogen, Zarxio, Granix, Nivestym) (CP.PHAR.297)
  • Fingolimod (Gilenya) (CP.PHAR.251)
  • Fosdenopterin (CP.PHAR.471)
  • Gabapentin ER (Gralise, Horizant) (CP.PMN.240)
  • Glatiramer (Copaxone, Glatopa) (CP.PHAR.252)
  • GLP-1 receptor agonists (HIM.PA.53)
  • Halobetasol-Tazarotene (Duobrii) (CP.PMN.208)
  • House Dust Mite Allergen Extract (Odactra) (CP.PMN.111)
  • Hydroxyprogesterone caproate (Makena) (CP.PHAR.14)
  • Idecabtagene Vicleucel (BB2121) (CP.PHAR.481)
  • Immune Globulins (CP.PHAR.103)
  • Indacaterol/Glycopyrrolate (Utibron Neohaler) (HIM.PA.102)
  • Inebilizumab (CP.PHAR.458)
  • Infertility and Fertility Preservation (CP.PHAR.131)
  • Interferon beta-1a (Avonex, Rebif) (CP.PHAR.255)
  • Interferon beta-1b (Betaseron, Extavia) (CP.PHAR.256)
  • Itraconazole (Sporanox ,Onmel, Tolsura) (CP.PMN.124)
  • Ivacaftor (Kalydeco) (CP.PHAR.210)
  • KTE-X19 (Tecartus) (CP.PHAR.472)
  • Lactitol (Pizensy) (CP.PMN.241)
  • Larotrectinib (Vitrakvi) (CP.PHAR.414)
  • Ledipasvir/Sofosbuvir (Harvoni) (CP.PCH.19)
  • Ledipasvir/Sofosbuvir (Harvoni) (HIM.PA.SP3)
  • Lisocabtagene Maraleucel (JCAR017) (CP.PHAR.483)
  • Lonafarnib (Zokinvy) (CP.PHAR.499)
  • Lorcaserin (Belviq, Belviq XR) (CP.PCH.03)
  • Lumacaftor-ivacaftor (Orkambi) (CP.PHAR.213)
  • Lumasiran (ALN-GO1) (CP.PHAR.473)
  • Lurbinectedin (Zepzelca) (CP.PHAR.500)
  • Lutetium Lu 177 dotatate (Lutathera) (CP.PHAR.384)
  • Mecasermin (Increlex) (CP.PHAR.150)
  • Mechlorethamine (Valchlor) (CP.PHAR.381)
  • Memantine (Namenda XR, Namzaric) (CP.PCH.30)
  • Methoxy polyethylene glycol-epoetin beta (Mircera) (CP.PHAR.238)
  • Mitomycin for Pyelocalyceal Solution (Jelmyto) (CP.PHAR.495)
  • Mitoxantrone (Novantrone) (CP.PHAR.258)
  • Mometasone (Nasonex) (HIM.PA.93)
  • Monomethyl fumarate (Bafiertam) (CP.PHAR.460)
  • Natalizumab (Tysabri) (CP.PHAR.259)
  • Natalizumab (Tysabri) (HIM.PA.SP17)
  • Nusinersen (Spinraza) (CP.PHAR.327)
  • Ocrelizumab (Ocrevus) (CP.PHAR.335)
  • Olanzapine Long-Acting Injection (Zyprexa Relprevv) (CP.PHAR.292)
  • Onasemnogene Abeparvovec (Zolgensma) (CP.PHAR.421)
  • Opicapone (Ongentys) (CP.PMN.245)
  • Osilodrostat (Isturisa) (CP.PHAR.487)
  • Overactive Bladder Agents (CP.PMN.198)
  • Ozanimod (Zeposia) (CP.PHAR.462)
  • Paliperidone Long-Acting Injections (Invega Sustenna, Invega Trinza) (CP.PHAR.291)
  • Panobinostat (Farydak) (CP.PHAR.382)
  • Pazopanib (Votrient) (CP.PHAR.81)
  • Pegfilgrastim (Neulasta), Pegfilgrastim-jmdb (Fulphila), Pegfilgrastim-cbqv (Udenyca), Pegfilgrastim-bmez (Ziextenzo) (CP.PHAR.296)
  • Peginterferon Alfa-2a,b (Pegasys, PegIntron, Sylatron) (CP.PHAR.89)
  • Peginterferon beta-1a (Plegridy) (CP.PHAR.271)
  • Pemigatinib (Pemazyre)(CP.PHAR.496)
  • Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo) (CP.PHAR.501)
  • Phendimetrazine (Bontril PDM) (HIM.PA.114)
  • Phentermine (Adipex-P, Lomaira) (CP.PCH.13)
  • Pimavanserin (Nuplazid) (CP.PMN.140)
  • Pirfenidone (Esbriet) (CP.PHAR.286)
  • Polatuzumab vedotin-piiq (Polivy) (CP.PHAR.433)
  • Progesterone (Crinone, Endometrin, Milprosa) (CP.PMN.243)
  • Pyrimethamine (Daraprim) (CP.PMN.44)
  • Remestemcel-L (Prochymal) (CP.PHAR.474)
  • Rimegepant (Nurtec ODT) (CP.PHAR.490)
  • Ripretinib (Qinlock) (CP.PHAR.502)
  • Risdiplam (Evrysdi) (CP.PHAR.477)
  • Rituximab (Rituxan, Ruxience, Truxima, Rituxan Hycela) (CP.PHAR.260)
  • Romiplostim (Nplate) (CP.PHAR.179)
  • Sacituzumab govitecan-hziy (Trodelvy) (CP.PHAR.475)
  • Satralizumab (CP.PHAR.463)
  • Selpercatinib (Retevmo) (CP.PHAR.478)
  • Setmelanotide (RM-493) (CP.PHAR.491)
  • Short Ragweed Pollen Allergen Extract (Ragwitek) (CP.PMN.83)
  • Siponimod (Mayzent) (CP.PHAR.427)
  • Sofosbuvir (Sovaldi) (CP.PCH.20)
  • Sofosbuvir (Sovaldi) (HIM.PA.SP2)
  • Somatropin (Human Growth Hormone) (CP.PHAR.55)
  • Somatropin (Human Growth Hormone_HGH) (CP.PCH.25)
  • Sutimlimab (CP.PHAR.503)
  • Talazoparib (Talzenna) (CP.PHAR.409)
  • Tazarotene (Arazlo, Fabior, Tazorac) (CP.PMN.244)
  • Teplizumab (PRV-031) (CP.PHAR.492)
  • Teriflunomide (Aubagio) (CP.PHAR.262)
  • Tetrabenazine (Xenazine) (CP.PHAR.92)
  • Thyrotropin Alfa (Thyrogen) (CP.PHAR.95)
  • Topical Diclofenac (Solaraze, Flector) (HIM.PA.123)
  • Treprostinil (Orenitram, Remodulin, Tyvaso) (CP.PHAR.199)
  • Trifluridine-tipiracil (Lonsurf) (CP.PHAR.383)
  • Tucatinib (Tukysa) (CP.PHAR.497)
  • Valoctocogene Roxaparvovec (CP.PHAR.466)
  • Viltolarsen(Viltepso) (CP.PHAR.484)
  • Voclosporin (CP.PHAR.504)

To review new policy overviews or updated policy revisions, please visit: Effective November 17, 2020: Pharmacy and Biopharmacy Policies

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.