Effective October 1, 2026: Pharmacy and Biopharmacy Policies
Date: 09/21/26
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 October 1, 2026, at 12:00 AM.
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 |
OnabotulinumtoxinA (Botox) (CP.PHAR.232) | Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter | For pediatric limb spasticity, added maximum recommended dose for the treatment of both lower limbs per prescribing information. |
Rituximab (RItuxan, Truxima, Riabni, Zimrixby, Ruxience, Rituxan Hycela) (CP.PHAR.260) | Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter | Added newly FDA approved biosimilar Zimrixby to criteria; updated Appendix E with revised language for Tennessee. |
Asciminib (Scemblix) (CP.PHAR.565) | Ambetter | 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. |
Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) (CP.PHAR.582) | Ambetter | Added new indication for mAPMN/S prostate cancer and added updated nomenclature for mCRPC to mAPMR prostate cancer per Prescribing Information. |
Marstacimab-hncq (Hympavzi) (CP.PHAR.674) | Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter | Added the indications of hemophilia A and B with inhibitors, updated indication to include pediatric patients 6-11 years of age, and added new 75 mg/0.5 mL strengths of prefilled dose and pen; added bypassing agent prophylaxis option to hemophilia severity requirement for members who are new to Hympavzi; added option to bypass failure of prophylaxis agents with ≥ 6 acute bleeding episodes in the previous 6 months treated with a bypassing agent, FVIII, or FIX product; added option of failure with bypassing agent prophylaxis in addition to either a FVIII or FIX product; removed requirement for no documented history of inhibitors; added ICHRA line of business. |
Nipocalimab-aahu (Imaavy) (CP.PHAR.720) | Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter | Added criteria for the newly approved indication of wAIHA; for gMG, added Uplizna to the list of therapies Imaavy should not be prescribed concurrently with. |
Lerodalcibep-liga (Lerochol) (CP.PHAR.768) | Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter | Added new autoinjector dosage form. |
Vusolimogene Oderparepvec-wtpg (Tudriqev) (CP.PHAR.774) | Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter | Policy created pre-emptively. |
Daraxonrasib (Rasonque) (CP.PHAR.794) | Ambetter | Drug is now FDA approved - criteria updated per FDA labeling: revised “pancreatic ductal adenocarcinoma” to “pancreatic adenocarcinoma”; added bypass of required prior therapy if provider attests that member is not a candidate for multiagent systemic therapy; removed requirement that member has an Eastern Cooperative Oncology Group performance status score of 0 or 1; removed requirement that member does not have known central nervous system metastases; updated dosing requirements; references reviewed and updated. |
GLP-1 receptor agonists (CP.PMN.183) | Medicaid | Updated criteria to reflect Mounjaro’s new FDA indication for reduction of major adverse cardiovascular events in diabetic patients at high risk. |
Semaglutide (Wegovy) (CP.PMN.295) | Ambetter | Added Mounjaro as an additional required redirection for members with concurrent T2DM; Updated redirection to preferred GLP-1 receptor agonist therapies from “failure of all of the following” to “three of the following” for members with concurrent T2DM. |
Tirzepatide (Zepbound) (CP.PMN.298) | Ambetter | Added Mounjaro as an additional required redirection for members with concurrent T2DM; updated redirection to preferred GLP-1 receptor agonist therapies from “failure of all of the following” to “three of the following” for members with concurrent T2DM. |
GLP-1 receptor agonists (HIM.PA.53) | Ambetter | Removed age requirement for allpreferred GLP-1 receptor agonist therapiesy;, for T2DM, removed “if age > 18 years” for Ozempic and Rybelsus redirection and added “unless FDA-approved age limit does not overlap” for redirected agents; added Mounjaro to Section I.A as a preferred GLP-1 receptor agonist therapy; for non-preferred agents in Section I.B, added redirection to Mounjaro as an option; updated redirection to preferred GLP-1 receptor agonist therapies from “failure of all of the following” to “three of the following”; added ICHRA line of businessremoved criteria for “ if request is for Victoza, member must use generic liraglutide” from Section I.A preferred agents and moved to Section I.V non-preferred agents to clarify correction for non-preferred brand Victoza requests; added ICHRA line of business; updated criteria to reflect Mounjaro’s new FDA indication for reduction of major adverse cardiovascular events in diabetic patients at high risk. |
Vusolimogene Oderparepvec (RP1)_PEPP (RETIRE_CP.PHAR.774 _PEPP) | Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter | Retire PEPP criteria is now live |
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.