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Effective October 1, 2025: Pharmacy and Biopharmacy Policies

Date: 07/16/25

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 October 1, 2025, at 12:00AM.

POLICY

APPLICABLE PRODUCTS

NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS

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

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

Policy updates include:

  • Food and Drug Administration (FDA) Approved Indication(s) section and criteria to reflect revised indication that limits use to tumors expressing programmed death-ligand 1 (PD-L1) (1 or higher) in combination with chemotherapy for unresectable advanced or metastatic esophageal squamous cell carcinoma in first-line setting and gastric cancer, gastroesophageal junction cancer and esophageal adenocarcinoma (previously approved regardless of programmed death-ligand 1 (PD-L1) status)
  • For microsatellite instability-high (MSI-H) or mismatch repair deficient (dmmr) esophageal cancers, specified usage as perioperative therapy when prescribed as a single age, as induction or palliative therapy when prescribed combination with fluoropyrimidine-containing chemotherapy, and as induction, neoadjuvant, perioperative, or palliative when prescribed in combination with Yervoy

Ipilimumab (Yervoy) (CP.PHAR.319)

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

Policy updates include:

  • Updated Food and Drug Administration (FDA) Approved Indication(s) section and criteria to reflect revised indication that limits use to tumors expressing programmed death-ligand 1 (PD-L1) (1 or higher) for unresectable advanced or metastatic esophageal squamous cell carcinoma in combination with Yervoy per updated PI (previously approved regardless of programmed death-ligand 1 (PD-L1) status)
  • Also for esophageal squamous cell carcinoma, added option to be prescribed as palliative therapy and clarified when prescribed as induction, neoadjuvant, perioperative, or palliative therapy that tumor is characterized as microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR).

Letermovir (Prevymis) (CP.PHAR.367)

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

Policy updates include:

  • For prophylaxis of cytomegalovirus in kidney transplant recipients, added criterion limiting usage of Prevymis up to day 200 post-transplantation

Adagrasib (Krazati) (CP.PHAR.605)

Ambetter

Policy updates include:

  • for colorectal cancer, added redirection to Lumakras

 

Brimonidine (Mirvaso) (CP.PMN.192)

Ambetter

Policy updates include:

  • Added redirection for brand Mirvaso requests to generic topical brimonidine

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.