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Effective November 1, 2025: Pharmacy and Biopharmacy Policies

Date: 10/16/25

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 November 1, 2025, 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

Dupilumab (Dupixent) (CP.PHAR.336)

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

Policy updates include:

  • Added new indication for bullous pemphigoid per updated prescribing information

Sepiapterin (Sephience) (CP.PHAR.708)

Ambetter

Policy includes:

  • Requests for indications not approved by the FDA are reviewed with the off-label use policy for the relevant line of business: HIM.PHAR.154 for Ambetter
  • Initial Approval Criteria: Phenylketonuria (PKU) (must meet all):
    • Diagnosis of hyperphenylalaninemia due to PKU;
    • Prescribed by or in consultation with an endocrinologist, metabolic disease specialist, or genetic disease specialist;
    • Recent (within 90 days) phenylalanine (Phe) blood level is at least 360 µmols/L;
    • Member is currently on a Phe-restricted diet and will continue this diet during treatment with Sephience;
    • Failure of generic sapropterin (Kuvan®) at up to maximally indicated doses, unless contraindicated or clinically significant adverse effects are experienced;
    • Sephience is not prescribed concurrently with sapropterin (Kuvan) or Palynziq™;
    • Documentation of member’s current weight (in kg);
    • Dose does not exceed 60 mg/kg per day.
    • Approval duration: 6 months
  • Continued Therapy: Phenylketonuria (must meet all):
    • Member meets one of the following:
      • Currently receiving medication via Centene benefit or member has previously met initial approval criteria;
      • Member is currently receiving medication and is enrolled in a state and product with continuity of care regulations;
    • Member is responding positively to therapy as demonstrated by a reduction in Phe blood levels since initiation of therapy;
    • Member is currently on a Phe-restricted diet and will continue this diet during treatment with Sephience;
    • Sephience is not prescribed concurrently with sapropterin (Kuvan) or Palynziq;
    • Documentation of member’s current weight (in kg);
    • If request is for a dose increase, new dose does not exceed 60 mg/kg per day.
    • Approval duration: 12 months

Donidalorsen (Dawnzera) (CP.PHAR.717)

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

Policy includes:

  • Criteria is only applicable for Medicaid and CHIP when the drug is added to the formulary for coverage
  • Requests for indications not approved by the FDA are reviewed with the off-label use policy for the relevant line of business: HIM.PHAR.154 for Ambetter, and CP.PMN.53 for Medicaid and CHIP
  • Initial Approval Criteria: Hereditary Angioedema (HAE) (must meet all):
    • Diagnosis of HAE confirmed by both of the following;
      • History of recurrent angioedema;
      • Low complement component 4 (C4) level and low C1 esterase inhibitor (C1-INH) antigenic or functional level;
    • Prescribed by or in consultation with an allergist, hematologist, or immunologist;
    • Age at least 12 years;
    • Prescribed for long-term prophylaxis of HAE attacks and request meets one of the following:
      • Member experiences more than one severe event per month;
      • Member is disabled more than five days per month;
      • Member has history of previous airway compromise;
    • Member is not using Dawnzera in combination with another FDA-approved product for long-term prophylaxis of HAE attacks;
    • Dose does not exceed 80 mg every 4 weeks.
    • Approval duration: 12 months
  • Continued Therapy: Hereditary Angioedema (must meet all):
    • Member meets one of the following:
      • Currently receiving medication via Centene benefit or member has previously met initial approval criteria;
      • Member is currently receiving medication and is enrolled in a state and product with continuity of care regulations;
    • Member is responding positively to therapy as evidenced by reduction in attacks from baseline;
    • Member is not using Dawnzera in combination with another Food and Drug Administration (FDA)-approved product for long-term prophylaxis of HAE attacks;
    • If request is for a dose increase, new dose does not exceed 80 mg every 4 weeks.
    • Approval duration: 12 months

 

Dupilumab (Dupixent) (HIM.PA.SP69)

Ambetter

Policy updates include:

  • Added new indication for bullous pemphigoid per updated prescribing information

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.