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Effective December 1, 2025: Pharmacy and Biopharmacy Policies

Date: 11/18/25

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 December 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

Delgocitinib (Anzupgo) (CP.PHAR.744)

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
    • Chronic Hand Eczema (CHE) (must meet all):
      • Diagnosis of CHE;
      • Member has hand eczema that has persisted for greater than 3 months or returned twice or more within the last 12 months;
      • Provider attestation that member has moderate to severe hand;
      • Prescribed by or in consultation with a dermatologist or allergist;
      • Age at least 18 years;
      • One of the following:
        • For Illinois HIM requests only: Failure of one formulary topical corticosteroid, unless clinically significant adverse effects are experienced or all are contraindicated;
        • For all other requests:  Failure of both of the following (i and ii), unless clinically significant adverse effects are experienced or all are contraindicated;
          • One formulary topical corticosteroid used for at least 2 weeks;
          • One of the following:
            • A second formulary topical corticosteroid used for at least 2 weeks;
            • One topical calcineurin inhibitor used for at least 4 weeks;     
      • Anzupgo is not prescribed concurrently with biologic medications (e.g., Dupixent ®, Adbry®), biologic disease-modifying antirheumatic drugs (e.g., Humira®, Enbrel®, Taltz®, Stelara®), JAK inhibitors (e.g., Cibinqo®, Opzelura™, Xeljanz®, Rinvoq®, Olumiant®), or potent immunosuppressants (e.g., azathioprine, cyclosporine);
      • Dose does not exceed both of the following:
        • One 30-gram tube per 2 weeks;
        • 60 grams per month.
      • Approval duration: 6 months
  • Continued Therapy
    • Chronic Hand Eczema (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, including but not limited to, reduction in itching and scratching, no signs of erythema, scaling, hyperkeratosis/lichenification, vesiculation, edema, or fissures;
      • Anzupgo is not prescribed concurrently with biologic medications (e.g., Dupixent, Adbry), biologic disease-modifying antirheumatic drugs (e.g., Humira, Enbrel, Taltz, Stelara), JAK inhibitors (e.g., Cibinqo, Opzelura, Xeljanz, Rinvoq, Olumiant), or potent immunosuppressants (e.g., azathioprine, cyclosporine);
      • If request is for a dose increase, new dose does not exceed both of the following:
        • One 30-gram tube per 2 weeks;
        • 60 grams per month.
      • Approval duration: 12 months

Pegcetacoplan (Empaveli, Syfovre) (CP.PHAR.524)

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

Policy updates include:

  • Added criteria for new Food and Drug Administration (FDA)-approved indication of C3 Glomerulopathy, Primary Immune-Complex Membranoproliferative Glomerulonephritis (C3G/primary IC-MPGN) for Empaveli

Dordaviprone (Modeyso) (CP.PHAR.745)

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
    • Diffuse Midline Glioma (must meet all):
      • Diagnosis of diffuse midline glioma;
      • Prescribed by or in consultation with an oncologist;
      • Age at least 1 year;
      • Disease has both of the following characteristics:
        • Presence of H3 K27M mutation;
        • Progressive following prior therapy (includes radiation therapy);
      • For Modeyso requests, member must use dordaviprone, if available, unless contraindicated or clinically significant adverse effects are experienced;
      • Request meets one of the following:
        • Dose does not exceed one of the following:
          • Adults: 625 mg per week;
          • Pediatrics:
            • Weight 10 kg to less than 12.5 kg: 125 mg per week;
            • Weight 12.5 kg to less than 27.5 kg: 250 mg per week;
            • Weight 27.5 kg to less than 42.5 kg: 375 mg per week;
            • Weight 42.5 kg to less than 52.5 kg: 500 mg per week;
            • Weight at least 52.5 kg: 625 mg per week;
        • Dose is supported by practice guidelines or peer-reviewed literature for the relevant off-label use (prescriber must submit supporting evidence). *Prescribed regimen must be FDA-approved or recommended by NCCN
      • Approval duration: 12 months

 

  • Continued Therapy
    • Diffuse Midline Glioma (must meet all):
      • Currently receiving medication via Centene benefit, or documentation supports that member is currently receiving Modeyso for a covered indication and has received this medication for at least 30 days;
      • Member is responding positively to therapy;
      • For Modeyso requests, member must use dordaviprone, if available, unless contraindicated or clinically significant adverse effects are experienced;
        • If request is for a dose increase, request meets one of the following:
          • New dose does not exceed one of the following:
            • Adults: 625 mg per week;
            • Pediatrics:
              • Weight 10 kg to less than 12.5 kg: 125 mg per week;
              • Weight 12.5 kg to less than 27.5 kg: 250 mg per week;
              • Weight 27.5 kg to less than 42.5 kg: 375 mg per week;
              • Weight 42.5 kg to less than 52.5 kg: 500 mg per week;
              • Weight at least 52.5 kg: 625 mg per week;
        • New dose is supported by practice guidelines or peer-reviewed literature for the relevant off-label use (prescriber must submit supporting evidence). *Prescribed regimen must be FDA-approved or recommended by NCCN
      • Approval duration: 12 months

 

Zongertinib (Hernexeos) (CP.PHAR.750)

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
    • Non-Small Cell Lung Cancer(NSCLC) (must meet all):
      • Diagnosis of unresectable, recurrent, advanced, or metastatic NSCLC;
      • Prescribed by or in consultation with an oncologist;
      • Age at least 18 years;
      • Prescribed as single agent;
      • Disease has activating HER2 (ERBB2) mutations;
      • Failure of a prior systemic therapy;
      • For Hernexeos requests, member must use zongertinib, if available, unless contraindicated or clinically significant adverse effects are experienced;
      • Request meets one of the following:
        • Dose does not exceed one of the following:
          • For body weight less than 90 kg: 120 mg (2 tablets) per day;
          • For body weight at least 90 kg: 180 mg (3 tablets) per day;
        • Dose is supported by practice guidelines or peer-reviewed literature for the relevant off-label use (prescriber must submit supporting evidence). *Prescribed regimen must be FDA-approved or recommended by NCCN
      • Approval duration: 12 months
  • Continued Therapy
    • Non-Small Cell Lung Cancer (must meet all):
      • Currently receiving medication via Centene benefit, or documentation supports that member is currently receiving Hernexeos for a covered indication and has received this medication for at least 30 days;
      • Member is responding positively to therapy;
      • For Hernexeos requests, member must use zongertinib, if available, unless contraindicated or clinically significant adverse effects are experienced;
      • If request is for a dose increase, request meets one of the following:
        • New dose does not exceed one of the following:
          • For body weight less than 90 kg: 120 mg (2 tablets) per day;
          • For body weight at least 90 kg: 180 mg (3 tablets) per day;
        • New dose is supported by practice guidelines or peer-reviewed literature for the relevant off-label use (prescriber must submit supporting evidence). *Prescribed regimen must be FDA-approved or recommended by NCCN
      • Approval duration: 12 months

Rilzabrutinib (Wayrilz) (CP.PHAR.751)

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
    • Immune Thrombocytopenia (must meet all):
      • Diagnosis of persistent or chronic ITP;
      • Prescribed by or in consultation with a hematologist;
      • Age at least 18 years;
      • One of the following:
        • Current (within 30 days) platelet count less than 30,000/µL;
        • Member has an active bleed;
      • Member meets one of the following:
        • Failure of a systemic corticosteroid;
        • Member has intolerance or contraindication to systemic corticosteroids, and failure of an immune globulin, unless contraindicated or clinically significant adverse effects are experienced (see Appendix B);
        • *Prior authorization may be required for immune globulins
      • Wayrilz is not prescribed concurrently with rituximab, a thrombopoietin receptor agonist (e.g., Doptelet®, Promacta®, Mulpleta®, Nplate®), or spleen tyrosine kinase inhibitor (e.g., Tavalisse™);
      • Dose does not exceed 800 mg (2 tablets) per day.
      • Approval duration: 12 months

 

  • Continued Therapy
    • Immune Thrombocytopenia (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 (e.g., increase in platelet count from baseline, reduction in bleeding events);
          • Wayrilz is not prescribed concurrently with rituximab, a thrombopoietin receptor agonist (e.g., Doptelet, Promacta, Mulpleta, Nplate), or spleen tyrosine kinase inhibitor (e.g., Tavalisse);
          • If request is for a dose increase, new dose does not exceed 800 mg (2 tablets) per day.
          • Approval duration: 12 months

 

Aceclidine (Vizz) (CP.PMN.302)

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.
    • Presbyopia (must meet all):
      • Diagnosis of presbyopia;
      • Prescribed by or in consultation with an optometrist or ophthalmologist;
      • Age between 45 and 75 years at the time of therapy initiation;
      • Failure of corrective eyeglasses or contact lenses to resolve the presbyopia symptoms, unless contraindicated or clinically significant adverse effects are experienced;
        Vizz is not prescribed concurrently with Vuity® or Qlosi™;
      • Dose does not exceed 2 drops per eye per day
      • Approval duration: 12 months
  • Continued Therapy
    • Presbyopia (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;
      • If request is for a dose increase, new dose does not exceed 2 drops per eye per day.
      • Approval duration: 12 months

Brensocatib (Brinsupri) (CP.PMN.303)

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
    • Non-Cystic Fibrosis Bronchiectasis (must meet all):
      • Diagnosis of non-cystic fibrosis bronchiectasis confirmed by chest computed tomography (CT) scan;
      • Prescribed by or in consultation with a pulmonologist;
      • Age at least 12 years;
      • Provider attestation that member is currently receiving optimal supportive therapy (examples include but are not limited to: airway clearance techniques, pulmonary rehabilitation, mucoactives [e.g., nebulized hypertonic saline, mannitol, dornase alfa, acetylcysteine], antibiotics [e.g., oral – azithromycin, erythromycin; inhaled – tobramycin, aztreonam]);
      • Documentation of one of the following despite at least 3 months of optimal supportive therapy:
        • Adults (age at least 18 years): Member has had at least 2 pulmonary exacerbations requiring systemic antibiotics in the last 12 months;
        • Pediatrics (age 12 to 17 years): Member has had at least 1 pulmonary exacerbation requiring systemic antibiotics in the last 12 months;
      • Member is not an active smoker as evidenced by recent (within the last 30 days) negative nicotine metabolite (i.e., cotinine) test;
      • Member does not have a primary* diagnosis of asthma or chronic obstructive pulmonary disease; *Secondary (comorbid) diagnoses of asthma or chronic obstructive pulmonary disease are allowable
      • Dose does not exceed 25 mg (1 tablet) per day.
      • Approval duration: 12 months
  • Continued Therapy
    • Non-Cystic Fibrosis Bronchiectasis (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;
      • If request is for a dose increase, new dose does not exceed 25 mg (1 tablet) per day.
      • Approval duration: 12 months

Gemcitabine Intravesical System (Inlexzo) (CP.PHAR.753)

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
    • Non-Muscle Invasive Bladder Cancer (NMIBC) (must meet all):
      • Diagnosis of NMIBC with carcinoma in-situ;
      • Prescribed by or in consultation with an oncologist or urologist;
      • Age at least 18 years;
      • Member is refractory to  bacillus Calmette-Guerin (BCG)* treatment; *Prior authorization may be required for BCG immunotherapy
      • Member is not a candidate for cystectomy;
      • Member has previously undergone transurethral resection of bladder tumor (TURBT);
      • Request meets one of the following:
        • Dose does not exceed 225 mg once every 3 weeks for 8 instillations, followed by once every 12 weeks for 6 instillations;
        • Dose is supported by practice guidelines or peer-reviewed literature for the relevant off-label use (prescriber must submit supporting evidence).
      • Approval duration: 12 months

 

  • Continued Therapy
    • Non-Muscle Invasive Bladder Cancer (must meet all):
      • Currently receiving medication via Centene benefit, or documentation supports that member is currently receiving Inlexzo for a covered indication and has received this medication for at least 30 days;
      • Member is responding positively to therapy as evidenced by lack of disease recurrence or progression;
      • Member has not received at least 14 instillations;
      • If request is for a dose increase, request meets one of the following:
        • If member has received < 8 instillations: New dose does not exceed 225 mg once every 3 weeks for up to 8 total instillations, followed by once every 12 weeks for 6 instillations;
        • If member has received at least 8 instillations: New dose does not exceed 225 mg once every 12 weeks for up to 6 total instillations;
        • New dose is supported by practice guidelines or peer-reviewed literature for the relevant off-label use (prescriber must submit supporting evidence).
      • Approval duration: 12 months

 

 

Imlunestrant (Inluriyo) (CP.PHAR.754)

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
    • Breast Cancer (must meet all):
      • Diagnosis of breast cancer;
      • Prescribed by or in consultation with an oncologist;
      • Age at least 18 years;
      • Disease has all of the following characteristics:
        • estrogen receptor (ER)-positive;
        • human epidermal growth factor receptor 2 (HER2) -negative;
        • estrogen receptor-1 (ESR1) -mutated;
        • Advanced (including locally advanced) or metastatic;
      • Disease has progressed following at least one line of endocrine therapy;
      • If member is a premenopausal or perimenopausal biological female, member has been treated with ovarian ablation or is receiving ovarian suppression;
      • If member is a biological male, member is receiving an agent that suppresses testicular steroidogenesis (e.g., gonadotropin-releasing hormone agonists);
      • For brand Inluriyo requests, member must use generic imlunestrant, if available, unless contraindicated or clinically significant adverse effects are experienced;
      • Request meets one of the following:
        • Dose does not exceed one of the following:
          • 400 mg (2 tablets) per day;
          • If member is receiving a concomitant strong CYP3A inducer (e.g., carbamazepine, fosphenytoin, phenytoin, rifampin): 600 mg (3 tablets) per day;
        • Dose is supported by practice guidelines or peer-reviewed literature for the relevant off-label use (prescriber must submit supporting evidence).
      •  Approval duration: 12 months

 

  • Continued Therapy
    • Breast Cancer (must meet all):
      • Currently receiving medication via Centene benefit, or documentation supports that member is currently receiving Inluriyo for breast cancer and has received this medication for at least 30 days;
      • Member is responding positively to therapy;
      • Dose is at least 200 mg per day;
      • For brand Inluriyo requests, member must use generic imlunestrant, if available, unless contraindicated or clinically significant adverse effects are experienced;
      • If request is for a dose increase, request meets one of the following:
        • New dose does not exceed one of the following:
          • 400 mg (2 tablets) per day;
          • If member is receiving a concomitant strong CYP3A inducer (e.g., carbamazepine, fosphenytoin, phenytoin, rifampin): 600 mg (3 tablets) per day;
        • New dose is supported by practice guidelines or peer-reviewed literature for the relevant off-label use (prescriber must submit supporting evidence).
        • Approval duration: 12 months

Paltusotide (Palsonify) (CP.PHAR.755)

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
    • Acromegaly (must meet all):
      • Diagnosis of acromegaly as evidenced by one of the following:
        • Pre-treatment insulin-like growth factor-I (IGF-I) level above the upper limit of normal based on age and gender for the reporting laboratory;
        • Serum growth hormone (GH) level at least 1 µg/L after a 2-hour oral glucose tolerance test;
      • Prescribed by or in consultation with an endocrinologist;
      • Age at least 18 years;
      • Inadequate response to surgical resection or pituitary irradiation, or member is not a candidate for such treatment;
      • Failure of Sandostatin® LAR Depot, unless contraindicated or clinically adverse effects are experienced; *Prior authorization may be required for Sandostatin LAR Depot
      • Dose does not exceed both of the following:
        • 60 mg per day;
        • 2 tablets per day.
      • Approval duration: 12 months
  • Continued Therapy
    • Acromegaly (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;
      • If request is for a dose increase, new dose does not exceed both of the following (a and b):
        • 60 mg per day;
        • 2 tablets per day.
      • Approval duration: 12 months

 

Remibrutinib (Rhapsido) (CP.PHAR.756)

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
    • Chronic Spontaneous Urticaria (CSU) (must meet all):
      • Diagnosis of CSU;
      • Prescribed by or in consultation with a dermatologist, immunologist, or allergist;
      • Age at least 18 years;
      • One of the following:
        • For Illinois HIM requests only: Failure of one antihistamine at maximum indicated doses used for at least 2 weeks, unless clinically significant adverse effects are experienced or all are contraindicated;
        • For all other requests: Failure of both of the following, unless clinically significant adverse effects are experienced or all are contraindicated (i and ii):
          • Two antihistamines (including one second generation antihistamine – e.g., cetirizine, levocetirizine, fexofenadine, loratadine, desloratadine) at maximum indicated doses, each used for at least 2 weeks;
          • A leukotriene modifier (LTRA) in combination with an antihistamine at maximum indicated doses for at least 2 weeks;
      • Rhapsido is not prescribed concurrently with Dupixent® or Xolair®;
      • Dose does not exceed 50 mg (2 tablets) per day.
      • Approval duration: 12 months
  • Continued Therapy
    • Chronic Spontaneous Urticaria (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;
      • Rhapsido is not prescribed concurrently with Dupixent or Xolair;
      • If request is for a dose increase, new dose does not exceed 50 mg (2 tablets) per day.
      • Approval duration: 12 months

Risperidone LA inj (Risperdal Consta, Perseris, Rykindo, Uzedy) (CP.PHAR.293)

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

Policy updates include:

  • Added new indication of bipolar 1 disorder for Uzedy

Pemetrexed (Alimta, Pemfexy, Axtle) (CP.PHAR.368)

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

Policy updates include:

  • Updated indication for Axtle to include combination with Keytruda and a platinum for non-small cell lung cancer
  • added off-label indication of thyroid carcinoma per National Comprehensive Cancer Network (NCCN) Compendium
  • updated HCPCS code description for J9292

Lenacapavir (Sunlenca, Yeztugo) (CP.PHAR.622)

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

Policy updates include:

  • Removed failure of Fuzeon per manufacturer discontinuation

Lidocaine transdermal (Bondlido, Lidoderm, ZTlido) (CP.PMN.08)

Ambetter

Policy updates include:

  • Added Bondlido as a new drug and dosage strength

Roflumilast (Daliresp, Zoryve) (CP.PMN.46)

Ambetter

Policy updates include:

  • Added Zoryve 0.05% cream to criteria with pediatric extension down to 2 years of age for atopic dermatitis

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.