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Effective September 1, 2024: Pharmacy and Biopharmacy Policies

Date: 06/18/24

Superior HealthPlan has added and updated 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 September 1, 2024, at 12:00AM.




Ruxolitinib (Jakafi, Opzelura) (CP.PHAR.98)


Policy updates include:

  • For atopic dermatitis and nonsegmental vitiligo, updated concurrent use criteria by adding “Opzelura is not prescribed concurrently with biologic medications (e.g., Dupixent, Adbry)” in initial and continued therapy sections

Alirocumab (Praluent) (CP.PHAR.124)

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

Policy updates include:

  • For all indications, revised criteria requires to require provider attestation rather than documentation, reduced statin adherence duration from 4 months to 8 weeks, simplified statin trial and failure criteria for moderate- and low-intensity statin regimens to require insufficient therapeutic response to one high intensity statin for 8 weeks or reversible muscle-related symptoms associated with both rosuvastatin and atorvastatin, removed ezetimibe trial criteria

Sotatercept (Winrevair) (CP.PHAR.657)

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

Policy updates include:

  • Drug is now Food and Drug Administration (FDA) approved – criteria updated per FDA labeling:
    • Added documentation of platelet count at least 50 x 109/L
    • Added quantity limit of one kit per 21 days
    • Added Appendix G for recommended vial quantity based on weight-based dose range
    • References reviewed and updated

Topical Acne Treatment (HIM.PA.71)


Policy updates include:

  • Removed Differin products from criteria (moved Differin criteria to HIM.PA.109 step therapy criteria)
  • Added Acanya and Onexton criteria
  • Revised BenzaClin criteria to apply to all brand or generic combination products (which includes BenzaClin)
  • For combination products, added requirement that the member must use generic combination product if available
  • For Evoclin, specified generic clindamycin per available formulary agents

Biologic and Non-biologic DMARDs (HIM.PA.SP60)


Policy updates include:

  • For plaque psoriasis, added redirection to Enbrel and Otezla as alternative option with “or” instead of “and” language to list of preferred redirected agents.                              
  • Added branded Cyltezo 40 mg/0.4 mL specific NDCs [0597-0495-40, 0597-0495-50, 0597-0495-60, 0597-0485-20] to list of preferred adalimumab products
  • For psoriatic arthritis and polyarticular juvenile idiopathic, added redirection to preferred agent Rinvoq LQ
  • For Entyvio, added new dosage form (subcutaneous injection) and removed “request is for intravenous formulation” for Crohn’s disease criteria
  • For psoriatic arthritis and plaque psoriasis, added newly approved biosimilar Selarsdi to criteria
  • For plaque psoriasis, updated Wezlana age requirement from > 18 years to > 6 years
  • For Otezla, added newly approved pediatric extension to 6 years and older for plaque psoriasis criteria
  • For Rinvoq, updated criteria to reflect pediatric extension to 2 years and older for psoriatic arthritis
  • For Rinvoq, added new FDA approved polyarticular juvenile idiopathic indication and added redirection to preferred agent Rinvoq LQ
  • For psoriatic arthritis and polyarticular juvenile idiopathic, added new oral solution dosage form [Rinvoq LQ] to criteria
  • For psoriatic arthritis, added redirection to preferred agent Stelara for pediatric Orencia requests
  • For Omvoh, added new dosage form [single-dose prefilled syringe 100 mg/mL]
  • For Cyltezo, added new 40 mg/0.4 mL dosage strengths for single-dose pen and single-dose prefilled syringe
  • For Appendix D, removed supplemental information on Deficiency of Interleukin-1 Receptor Antagonist (DIRA) indication and PHOENIX 2 trial for Stelara.

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.