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Effective May 1, 2026: Pharmacy and Biopharmacy Policies

Date: 04/22/26

Ambetter from Superior HealthPlan and 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 May 1, 2026, 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

Epinephrine (Epipen, Epipen Jr, Neffy, Auvi-Q) (CP.PCH.55)

Ambetter

Policy updates include:

  • For EpiPen and EpiPen Jr, updated indication and criteria include weight minimum per updated prescribing information
  • For Neffy, updated indication to remove age restriction per updated prescribing information.

Pomalidomide (Pomalyst) (CP.PHAR.116)

Ambetter

Policy updates include:

  • For all indications, added redirection to generic.

Nivolumab, Nivolumab Hyaluronidase-nvhy (Opdivo, Opdivo Qvantig) (CP.PHAR.121)

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

Policy updates include:

  • For classic Hodgkin lymphoma, added new indication for adult and pediatric patients with previously untreated Stage III or IV disease in combination with doxorubicin, vinblastine, darcarbazine and converted relapsed or progressed classic Hodgkin lymphoma from accelerated approval to full Food and Drug Administration (FDA)-approval
  • Per National Comprehensive Cancer Network (NCCN), for off-label classic Hodgkin lymphoma usages: clarified use in stage I or II in combination with doxorubicin, vinblastine, darcarbazine for unfavorable disease
  • For relapsed, refractory disease clarified usage as a single agent after at least 3 prior lines of therapy
  • For pediatric classic Hodgkin lymphoma, added use for relapsed or refractory disease
  • Updated Appendix F to include Indiana.

Venetoclax (Venclexta) (CP.PHAR.129)

Ambetter

Policy updates include:

  • Updated the conditions under which Venclexta can be used as first-line therapy for chronic lymphocytic leukemia / small lymphocytic lymphoma

Bortezomib (Boruzu, Velcade) (CP.PHAR.410)

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

Policy updates include:

  • Added J-codes for Boruzu, Velcade, and bortezomib in generic redirection criteria to clarify brand redirection to generic bortezomib

Human Growth Hormone (Somapacitan, Somatrogon, Somatropin, Lonapegsomatropin-tcgd) (CP.PHAR.517)

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

Policy updates include:

  • Per updated label for Sogroya, added new pediatric indications for short stature born small for gestational age, growth failure associated with Noonan syndrome, and idiopathic short stature

Pegzilarginase-nbln (Loargys) (CP.PHAR.587)

Ambetter

Policy updates include:

  • Drug is now Food and Drug Administration (FDA) approved – criteria updated per Food and Drug Administration (FDA) labeling: added criterion for member’s current weight
  • Added option of neurologist specialty
  • Added ICHRA line of business
  • Extended initial approval duration for Medicaid/HIM from 6 months to 12 months
  • Revised initial and continued Commercial approval durations 6 and 12 months to “6 months or to the member’s renewal date, whichever is longer”
  • Added HCPCS codes

Teclistamab-cqyv (Tecvayli) (CP.PHAR.611)

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

Policy updates include:

  • Added new Food and Drug Administration (FDA)-labeled indication of multiple myeloma in combination with daratumumab and hyaluronidase-fihj (Darzalex Faspro)
  • Updated existing indication of multiple myeloma as monotherapy from accelerated approval to full approval per prescribing information.

No Coverage Criteria, Recent Label Changes Pending Clinical Policy Update (CP.PMN.255)

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

Policy updates include:

  • For Appendix E, added states IN, MS, OH, and OK.

Brivaracetam (Briviact) (CP.PMN.297)

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

Policy updates include:

  • Revised policy/criteria section to also include generic brivaracetam
  • Added redirection to generic brivaracetam for brand Briviact requests.

Off-Label Use (CP.PMN.53)

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

Policy updates include:

  • For Appendix E, added states IN, MS, OH, and OK.

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.