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Effective July 1, 2026: Pharmacy and Biopharmacy Policies

Date: 06/22/26

Ambetter from Superior HealthPlan, Ambetter Health Solutions, 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 July 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

Selexipag (Uptravi) (CP.PHAR.196)

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

Policy updates include:

  • Updated to reflect pediatric extension for pulmonary arterial hypertension and added new 100 mcg and 150 mcg tablet dosage strengths

Trabectedin (Yondelis, Evdi) (CP.PHAR.204)

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

Policy updates include:

  • Added new formulation Evdi to policy

Atezolizumab (Tecentriq), Atezolizumab-Hyaluronidase (Tecentriq Hybreza) (CP.PHAR.235)

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

Policy updates include:

  • Added muscle invasive bladder cancer indication per updated package insert
  • For PD-L1 positive urothelial carcinoma, removed requirement for ineligibility for cisplatin-containing chemotherapy per National Comprehensive Cancer Network (NCCN)

Eribulin mesylate (Halaven) (CP.PHAR.318)

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

Policy updates include:

  • Added requirement that member must use generic eribulin mesylate for brand Halaven requests.

Durvalumab (Imfinzi) (CP.PHAR.339)

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

Policy updates include:

  • Added criteria for newly Food and Drug Administration (FDA)-approved indication of Bacillus Calmette-Guérin (BCG)-naïve, high-risk non-muscle-invasive bladder cancer
  • Added urologist prescriber option for muscle invasive bladder cancer

Fam-trastuzumab deruxtecan-nxki (Enhertu) (CP.PHAR.456)

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

Policy updates include:

  • Added two newly approved indications for use as adjuvant and neoadjuvant therapy in early breast cancer
  • Added ICHRA line of business

Decitabine-Cedazuridine (Inqovi) (CP.PHAR.479)

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

Policy updates include:

  • Added criteria for newly approved Food and Drug Administration (FDA) indication for acute myeloid leukemia

Efgartigimod alfa, efgartigimod-hyaluronidase (Vyvgart, Vyvgart Hytrulo) (CP.PHAR.555)

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

Policy updates include:

  • Updated generalized myasthenia gravis indication for expansion to all serotypes of generalized myasthenia gravis and added additional serotype criteria options
  • Added qualifier of anti- acetylcholine receptor (achr) antibody-positive generalized myasthenia gravis for required failure of a cholinesterase inhibitor
  • For concurrent therapy exclusions for generalized myasthenia gravis, added Uplizna

Zenocutuzumab-zbco (Bizengri) (CP.PHAR.713)

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

Policy updates include:

  • Added new Food and Drug Administration (FDA) approved indication for cholangiocarcinoma
  • Consolidated non-small cell lung cancer, pancreatic adenocarcinoma, and cholangiocarcinoma criteria into one section

Etuvetidigene Autotemcel (Waskyra) (CP.PHAR.735)

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

Policy updates include:

  • Added ICHRA line of business

Semaglutide (Wegovy) (CP.PMN.295)

Ambetter/ICHRA

Policy updates include:

  • New formulation Wegovy prefilled syringe to policy

Opioid Analgesics (HIM.PA.139)

Ambetter/ICHRA

Policy updates include:

  • For brand Nucynta ER, added requirement that member must use generic tapentadol ER

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.