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On Feb. 21, 2024, Change Healthcare experienced a cyber security incident. Any individuals impacted by this incident will receive a letter in the mail. Learn more about this from Change Healthcare, or reach out to the contact center at 1-866-262-5342.

Effective March 1, 2025: Pharmacy and Biopharmacy Policies

Date: 02/18/25

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 March 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

Encorafenib (Braftovi) (CP.PHAR.127)

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

Policy updates include:

  • Added newly Food and Drug Administration (FDA)-approved use in metastatic colorectal cancer in combination with cetuximab and mFOLFOX6.

Durvalumab (Imfinzi) (CP.PHAR.339)

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

Policy updates include:

  • Added criteria for newly Food and Drug Administration (FDA)-approved indication of limited-stage small cell lung cancer

Tislelizumab-jsgr (Tevimbra) (CP.PHAR.687)

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

Policy updates include:

  • Updated criteria to include new indication for gastric or gastroesophageal junction adenocarcinoma

Tapinarof (Vtama) (CP.PMN.283)

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

Policy updates include:

  • Added newly approved atopic dermatitis indication to criteria.

Hydroxyurea (Siklos, Xromi) (CP.PMN.193)

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

Policy updates include:

  • Revised Xromi indication for pediatric extension up to 18 years of age

Overactive Bladder Agents (CP.PMN.198)

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

Policy updates include:

  • For Gemtesa added additional indication for overactive bladder in adult males on pharmacological therapy for benign prostatic hyperplasia 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.