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Effective December 1, 2023: Pharmacy and Biopharmacy Policies

Date: 08/30/23

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, 2023, at 12:00AM.

POLICY

APPLICABLE PRODUCTS

NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS

Biologic and Non-biologic DMARDs (HIM.PA.SP60)

Ambetter

Policy updates include:

  • Added Humira biosimilars Abrilada, unbranded adalimumab-adaz, unbranded adalimumab-fkjp, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, and Yusimry to policy
  • For Amjevita request criteria, removed “preferred formulary” language
  • For ankylosing spondylitis, Crohn’s disease, plaque psoriasis, polyarticular juvenile idiopathic arthritis, psoriatic arthritis, rheumatoid arthritis, and ulcerative colitis, modified redirection from “Humira or Amjevita” to “one of the following adalimumab products: Humira, Hadlima, or adalimumab-adaz”
  • Added requirement for Humira biosimilars that member must use all preferred adalimumab products: Humira, Hadlima, and unbranded adalimumab-adaz (NDC 61314-0327-20, 61314-0327-96, 61314-0327-64, 61314-0327-94)
  • Removed criteria requiring use of preferred Amjevita NDCs and Appendix with Amjevita NDC references

Ferric Carboxymaltose (Injectafer) (CP.PHAR.234)

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

Policy updates include:

  • For iron deficiency anemia with and without chronic kidney disease, added redirections from initial approval criteria to continued therapy

Ferric Derisomaltose (Monoferric) (CP.PHAR.480)

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

Policy updates include:

  • Added redirections from initial approval criteria to continued therapy

Ferric Pyrophosphate Citrate (Triferic, Triferic Avnu) (CP.PHAR.624)

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

Policy updates include:

  • Added redirections from initial approval criteria to continued therapy

Ferumoxytol (Feraheme) (CP.PHAR.165)

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

Policy updates include:

  • Added redirections from initial approval criteria to continued therapy

GLP-1 receptor agonists (HIM.PA.53)

Ambetter

Policy updates include:

  • Added the following requirement to both initial and continued therapy: requested product is not prescribed concurrently with another glucagon-like peptide-1 receptor agonist

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.