Effective January 1, 2027: Pharmacy and Biopharmacy Policies
Date: 10/21/26
Ambetter from Superior HealthPlan, Ambetter Health (Solutions), and Superior HealthPlan (Medicaid and CHIP) 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 January 1, 2027, at 12:00 AM.
Policy | Applicable Products | New Policy Overview or Updated Policy Revisions |
Continuous Glucose Monitors (CP.PCH.64) | Ambetter, Ambetter Health | Policy created (adapted from CP.CPA.355) per August SDC: added HIM/ICHRA line of business. |
Biologic and Non-biologic DMARDs (ICHRA.PA.01) | Ambetter Health | Policy created per August SDC (adapted from HIM.PA.SP60; for CD, PsO, PsA, and UC, removed redirection to Tremfya and Stelara as agents are not preferred; removed step through criteria for initiating therapy for Stelara; added redirection to Imuldosa as agent is preferred). |
Inhaled asthma and COPD agents (ICHRA.PA.02) | Ambetter Health | Policy created per August SDC (adapted from HIM.PA.153; removed Asmanex HFA/Asmanex Twisthaler, Tudorza Pressair, and Bevespi Aerosphere from criteria as agents are preferred and added redirection to Asmanex HFA/Asmanex Twisthaler for ICS agents, redirection to Tudorza Pressair for LAMA agents, and redirection to Bevespi Aerosphere for LABA/LAMA agents. |
Insulin glargine (Basaglar, Langlara, Rezvoglar) (ICHRA.PA.03) | Ambetter Health | Policy created per August SDC (adapted from HIM.PA.09 with the following revisions: removed Lantus, Toujeo, and unbranded Toujeo from policy and added redirection to them as preferred products). |
Dapsone (Aczone Gel) (CP.PCH.32) | Ambetter, Ambetter Health | Per August SDC, removed Clindagel from Appendix B. |
Propranolol (Hemangeol) (CP.PCH.51) | Ambetter Health | Per August SDC: removed HIM line of business; added statement for California Exchange Plans should use CP.PMN.58 Propranolol HCl Oral Solution (Hemangeol) criteria. |
Immune Globulins (CP.PHAR.103) | Ambetter Health, Ambetter, and Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP | Per August SDC, added HIM and ICHRA line of business; updated Appendix G with revised language for Tennessee; for Nebraska HIM line of business, added allowance of bypassing the exclusion of PANDAS in section III per state regulations. |
Corticotropin (Acthar Gel, Purified Cortrophin Gel) (CP.PHAR.168) | Ambetter Health, Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), and CHIP | Per August SDC, added ICHRA line of business. |
Deutetrabenazine (Austedo, Austedo XR) (CP.PHAR.341) | Ambetter, Ambetter Health | Per August SDC, added HIM/ICHRA lines of business. |
Lanadelumab-fylo (Takhzyro) (CP.PHAR.396) | Ambetter Health, Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), and CHIP | Per August SDC, added ICHRA line of business. |
Berotralstat (Orladeyo) (CP.PHAR.485) | Ambetter Health | Per August SDC, added ICHRA line of business. |
Propranolol (Hemangeol) (CP.PMN.58) | Ambetter | Per August SDC, added HIM line of business. |
Isotretinoin (Claravis Absorica Absorica LD Myorisan Zenatane Amnesteem) (CP.PMN.143) | Ambetter, Ambetter Health | Per August SDC, removed Clindagel from Appendix B. |
Semaglutide (Wegovy) (CP.PMN.295) | Ambetter, Ambetter Health | Per August SDC: updated redirection to preferred GLP-1 receptor agonist therapies from “failure of three of the following” to “failure of all of the following” for members with concurrent T2DM. |
Tirzepatide (Zepbound) (CP.PMN.298) | Ambetter, Ambetter Health | Per August SDC: updated redirection to preferred GLP-1 receptor agonist therapies from “failure of three of the following” to “failure of all of the following” for members with concurrent T2DM. |
Insulin glargine (Basaglar, Lantus, Rezvoglar, Toujeo) (HIM.PA.09) | Ambetter | Per August SDC: for Focused plans, added statement that Lantus, Toujeo, and unbranded Toujeo do not require prior authorization and added redirection to them as preferred products. |
GLP-1 receptor agonists (HIM.PA.53) | Ambetter, Ambetter Health | Per August SDC: updated redirection to preferred GLP-1 receptor agonist therapies from “failure of three of the following” to “failure of all of the following.” |
DPP-4 inhibitors (HIM.PA.58) | Ambetter, Ambetter Health | Per August SDC: added brand Januvia, Janumet, and Janumet XR to policy with redirection to generic; added ICHRA line of business. |
Topical Acne Treatment (HIM.PA.71) | Ambetter, Ambetter Health | Per August SDC, removed Clindagel from Appendix B. |
SGLT2 inhibitors (HIM.PA.91) | Ambetter, Ambetter Health | Per August SDC: added brand Farxiga and Xigduo XR to criteria with redirection to generic; added ICHRA line of business. |
Inhaled asthma and COPD agents (HIM.PA.153) | Ambetter | Per August SDC: for Focused plans, added statement that Asmanex HFA, Asmanex Twisthaler, Tudorza Pressair, and Bevespi Aerosphere do not require prior authorization and added redirection to them as preferred products. |
Human Growth Hormone (Somapacitan, Somatrogon, Somatropin, Lonapegsomatropin-tcgd) (HIM.PA.161) | Ambetter, Ambetter Health | Per August SDC, removed Humatrope as a preferred drug. |
Corticotropin (H.P. Acthar, Purified Cortrophin Gel) (HIM.PA.168) | Ambetter | Per August SDC, removed ICHRA line of business, for Focused plans, added redirection of Acthar to Purified Cortrophin Gel. |
Berotralstat (Orladeyo) (HIM.PA.169) | Ambetter | Per August SDC, added redirection to Haegarda for Focused plans only. |
Lanadelumab-fylo (Takhzyro) (HIM.PA.172) | Ambetter | Per August SDC, added redirection to Haegarda for Focused plans only. |
Palbociclib (Ibrance) (HIM.PA.173) | Ambetter, Ambetter Health | Per August SDC: for breast cancer, removed redirection to Kisqali. |
Insulin Icodec-abae (Awiqli) (HIM.PA.180) | Ambetter, Ambetter Health | Per August SDC: for Focused plans, added redirection to Lantus, Toujeo, and unbranded Toujeo. |
Biologic and Non-biologic DMARDs (HIM.PA.SP60) | Ambetter | Per August SDC: for CD, PsO, PsA, and UC, removed redirection to Stelara as agent is not preferred; removed step through criteria for initiating therapy for Stelara; added redirection to Imuldosa as agent is preferred). |
Asciminib (Scemblix) (CP.PHAR.565) | Ambetter, Ambetter Health | For CML, changed use for TKI-experienced patients from those in CP to those in AP since Scemblix is FDA-approved as first-line therapy for CP-CML and since, per NCCN guidelines, Scemblix is considered “Useful in certain circumstances” for off-label AP-CML; added ICHRA line of business. |
Deutetrabenazine (Austedo, Austedo XR) (CP.PCH.42 ) | Ambetter | Retired, replaced by CP.CPA.370 and CP.PHAR.341 |
Testosterone (Androderm) (HIM.PA.87) | Ambetter | Retired per August SDC. |
Insulin detemir (Levemir) (HIM.PA.171) | Ambetter | Retired per August SDC. |
Immune Globulins (HIM.PA.178) | Ambetter | Retired per August SDC. |
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 the Centene Pharmacy Services (CPS) at 1-866-768-7147.