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Effective November 1, 2025: Pharmacy and Biopharmacy Policies

Date: 08/21/25

Ambetter from 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 November 1, 2025, at 12:00AM.

POLICY

APPLICABLE PRODUCTS

NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS

Niraparib (Zejula) (CP.PHAR.408)

Ambetter

Policy updates include:

  • Updated indication for maintenance treatment of adult patients with advanced ovarian cancer in the first-line setting with restriction to those with homologous recombination deficiency -positive tumors only
  • For ovarian cancer, added criteria for members with platinum-sensitive persistent or recurrent disease per National Comprehensive Cancer Network (NCCN) and revised tablet quantity limit from 3 tablets to 1 tablet

Mercaptopurine (Purixan) (CP.PHAR.447)

Ambetter

Policy updates include:

  • Added redirection to generic oral suspension
  • For redirection to mercaptopurine tablets revised verbiage from “member must use” to “failure of.”

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.