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Effective April 1, 2022: Pharmacy and Biopharmacy Policies

Date: 02/01/22

Superior HealthPlan has updated 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 April 1, 2022 at 12:00AM.

POLICY

APPLICABLE PRODUCTS

NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS

Amikacin (Arikayce) (CP.PHAR.401)

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

Policy updates include:

  • Added requirement that member has not received more than 12 months of treatment following conversion to negative sputum status to support existing continued authorization coverage duration requirements

Atezolizumab (Tecentriq) (CP.PHAR.235)

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

Policy updates include:

  • Removed breast cancer indication and added NSCLC stage II to IIIA treatment indication per updated label
  • Added criterion for use as single-agent therapy for urothelial carcinoma per NCCN
  • Added criterion for Child-Pugh class A status in HCC per NCCN

Avapritinib (Ayvakit) (CP.PHAR.454)

Ambetter

Policy updates include:

  • Added documentation of platelet count ≥ 50 x 109/L (≥ 50,000/mcL) based on NCCN Compendia and prescribing information for systemic mastocystosis

Avelumab (Bavencio) (CP.PHAR.333)

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

Policy updates include:

  • Added criterion that Bavencio be used as single-agent therapy for urothelial carcinoma per NCCN
  • Added endometrial carcinoma indication per NCCN

Brentuximab Vedotin (Adcetris) (CP.PHAR.303)

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

Policy updates include:

  • Initial approval duration shortened from 12 months to 6 months

C1 Esterase Inhibitors (Berinert Cinryze Haegarda Ruconest) (CP.PHAR.202)

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

Policy updates include:

  • Updated diagnosis criteria to include a recurrent history of angioedema and either an associated mutation or family history of angioedema with failure of high-dose antihistamines for HAE-nl-C1INH
  • Added criterion for age ≥ 18 years for Firazyr redirection
  • Clarified the number of doses for treatment of acute attacks and short-term prophylaxis within criteria
  • Added auth duration of 4 weeks for short-term prophylaxis

Ciclopirox (Penlac) (CP.PMN.24)

Ambetter

Policy updates include:

  • For continued therapy added criteria to ensure member has not received more than 48 weeks of treatment
  • Modified approval duration to allow up to 48 weeks of total treatment

Dupilumab (Dupixent) (CP.PHAR.336)

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

Policy updates include:

  • Expanded age to 6+ years old for asthma and added new 100 mg prefilled syringe formulation
  • Added “Acute bronchospasm or status asthmaticus” to section III as indications for which coverage is not authorized per PI

Ecallantide (Kalbitor) (CP.PHAR.177)

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

Policy updates include:

  • Updated diagnosis criteria to include a recurrent history of angioedema and either an associated mutation or family history of angioedema with failure of high-dose antihistamines for HAE-nl-C1INH
  • Clarified the number of doses for treatment of acute attacks and short-term prophylaxis within criteria

Efinaconazole (Jublia) (CP.PMN.25)

Ambetter

Policy updates include:

  • For continued therapy added criteria to ensure member has not received more than 48 weeks of treatment
  • Modified approval duration to allow up to 48 weeks of total treatment

Erwinia Asparaginase (Erwinaze, Rylaze) (CP.PHAR.301)

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

Policy updates include:

  • Specified only Erwinaze recommended for ALL induction therapy per NCCN

Fostemsavir (Rukobia) (CP.PHAR.516)

Ambetter

Policy updates include:

  • Clarified that HIV-1 infection should be multi-drug resistant per FDA labeling
  • Added requirement for documentation of resistance to at least 1 antiretroviral agent from each of 3 classes (NRTI, NNRTI, PI) as pivotal trial inclusion criteria limited enrollment to those with have ≤ 2 classes of antiretroviral medications remaining at baseline
  • Removed requirement for “3 month trial” of Selzentry/Fuzeon and added bypass if member is resistant to both, and revised language for concurrent use with other antiretrovirals

Givosiran (Givlaari) (CP.PHAR.457)

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

Policy updates include:

  • Clarified that ALA/PBG urine sample must be recent (within the past year)

Human Growth Hormone (Somapacitan, Somatropin) (CP.PHAR.517)

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

Policy updates include:

  • Modified Zomacton redirection to state member must use
  • For adult GHD continuation of therapy added requirement that member is responding positively to therapy
  • Sogroya added new 5 mg/1.5 mL formulation

Human Growth Hormone (Somapacitan, Somatropin)(HIM.PA.161)

Ambetter

Policy updates include:

  • For adult GHD continuation of therapy added requirement that member is responding positively to therapy
  • For ISS clarified that both height criteria are required (SD and predicted height)
  • Sogroya added new 5 mg/1.5 mL formulation

Ibrutinib (Imbruvica) (CP.PHAR.126)

Ambetter

Policy updates include:

  • Removed indication for CLL/SLL histologic (Richter's) transformation per NCCN as it is now category 2B
  • Added indication of lymphoplasmacytic lymphoma to WM criteria per NCCN
  • Updated primary CNS lymphoma criterion that ibrutinib may be used as either induction therapy or for relapsed or refractory disease per NCCN

Icatibant (Firazyr) (CP.PHAR.178)

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

Policy updates include:

  • Updated diagnosis criteria to include a recurrent history of angioedema and either an associated mutation or family history of angioedema with failure of high-dose antihistamines for HAE-nl-C1INH
  • Clarified the number of doses for treatment of acute attacks within criteria

Interferon Beta-1b (Betaseron, Extavia) (CP.PHAR.256 and CP.PCH.46)

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

Policy updates include:

  • Removed specialist prescribing requirement
  • Modified current Extavia redirection requirements to apply to Betaseron instead, removing redirection requirements for Extavi
  • For secondary progressive MS added requirement for Betaseron to require failure of an interferon beta agent

Lanadelumab-fylo (Takhzyro) (CP.PHAR.396)

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

Policy updates include:

  • Updated diagnosis criteria to include a recurrent history of angioedema and either an associated mutation or family history of angioedema with failure of high-dose antihistamines for HAE-nl-C1INH

Lifitegrast (Xiidra) (CP.PMN.73)

Ambetter

Policy updates include:

  • Added requirement for topical anti-inflammatory agents
  • Reduced the number of wetting agents required from 2 to 1
  • Removed duration of trial

Mepolizumab (Nucala) (CP.PHAR.200)

Ambetter

Policy updates include:

  • For EGPA, added diagnostic criteria and requirement for relapsing or refractory disease and modified glucocorticoid trial from 3 months to 4 weeks

Mometasone Furoate (Sinuva) (CP.PHAR.448)

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

Policy updates include:

  • Specified that one of the tried intranasal steroids must be Xhance

Nivolumab (Opdivo) (CP.PHAR.121)

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

Policy updates include:

  • Updates made per NCCN: for urothelial carcinoma removed requirement for resection to be radical as NCCN also supports partial resection prior to adjuvant therapy and added treatment option of high-risk recurrence as an optional criterion
  • Added cervical cancer as off-label indication
  • Updated gestational trophoblastic neoplasia treatment settings
  • Added criterion for use as single-agent therapy for SCCHN
  • Clarified uveal melanoma to be metastatic
  • Removed “metastatic” designation for Merkel cell carcinoma
  • Clarified small bowel adenocarcinoma be advanced or metastatic
  • Small cell lung cancer indication added
  • Clarified extranodal NK/T-cell lymphoma to be relapsed or refractory

Olaparib (Lynparza) (CP.PHAR.360)

Ambetter

Policy updates include:

  • Added that mutation analysis must be confirmed on a CLIA approved diagnostic test (e.g., Foundation One CDx or BRAC Analysis CDx)
  • Added in continued therapy section that total treatment duration as adjuvant therapy in breast cancer does not exceed 1 year

Ondansetron (Zuplenz) (CP.PMN.45)

Ambetter

Policy updates include:

  • Added age limits per PI

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

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

Policy updates include:

  • Added other sources of malignant mesotheliomas per NCCN
  • Added criterion for use as single-agent therapy for thymomas/thymic carcinomas, ovarian/fallopian tube/primary peritoneal cancers, and primary central nervous system lymphomas per NCCN

Pyrimethamine (Daraprim) (CP.PMN.44)

Ambetter

Policy updates include:

  • For continuation of therapy, added specific CD4 requirements for members aged < 6 years per HHS guidelines.

Ramucirumab (Cyramza) (CP.PHAR.119)

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

Policy updates include:

  • Revised criteria for advanced esophageal, EGJ or gastric cancer allowing combination with irinotecan with or without fluorouracil and added requirement for unresectable, locally advanced, recurrent, or metastatic disease per NCCN

Ranibizumab (Byooviz, Lucentis, Susvimo) (CP.PHAR.186)

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

Policy updates include:

  • Shortened approval durations from 12 months to 3 months for mCNV and 6 months for all other indications
  • Added Byoorivz and Susvimo to policy

Ravulizumab-cwvz (Ultomiris) (CP.PHAR.415)

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

Policy updates include:

  • For PNH, added requirement for no concurrent use with Empaveli
  • Added amyotrophic lateral sclerosis to section III as an indication not covered due to lack of efficacy

Repository Corticotropin Injection (H.P. Acthar Gel) (CP.PHAR.168)

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

Policy updates include:

  • Added Purified Cortrophin Gel to policy
  • For Acthar added step through Purified Cortrophin Gel
  • For infantile spasm added requirement that diagnosis is confirmed by EEG per competitor analysis

Rimegepant (Nurtec ODT) (CP.PHAR.490)

Ambetter

Policy updates include:

  • For migraine prophylaxis added redirection to newly approved oral CGRP Qulipta

Secnidazole (Solosec) (CP.PMN.103)

Ambetter

Policy updates include:

  • Specified that the requirement for the prior trial of the two generic ophthalmic agents be for agents from different therapeutic classes

Sodium Oxybate (Xyrem) and Calcium, Magnesium, Potassium, Sodium Oxybate (Xywav) (CP.PMN.42)

Ambetter

Policy updates include:

  • For narcolepsy with cataplexy added redirection to Xyrem for Xywav requests
  • For narcolepsy with EDS added requirement for redirection to Wakix (and for Xywav additional redirection to Xyrem) in a step-wise fashion

Tavaborole (Kerydin) (CP.PMN.105)

Ambetter

Policy updates include:

  • For continued therapy added criteria to ensure member has not received more than 48 weeks of treatment
  • Modified approval duration to allow up to 48 weeks of total treatment per prescribing information

Teduglutide (Gattex) (CP.PHAR.114)

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

Policy updates include:

  • Added minimum weight requirement based on prescribing information

Tenapanor (Ibsrela) (CP.PMN.224)

Ambetter

Policy updates include:

  • Added redirection to generic lubiprostone

Tisagenlecleucel (Kymriah) (CP.PHAR.361)

Ambetter

Policy updates include:

  • Added requirement that member has not previously received CAR-T therapy and Kymriah is not prescribed concurrently with other CAR-T therapy
  • For ALL clarified that hematopoietic stem cell transplantation should more specifically refer to allogeneic stem cell transplantation
  • Added preemptive criteria for the pending FDA approval of FL indication

Triamcinolone ER Injection (Zilretta) (CP.PHAR.371)

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

Policy updates include:

  • Added requirement for diagnosis to be confirmed by imaging and added sports medicine physician as acceptable specialist

Vandetanib (Caprelsa) (CP.PHAR.80)

Ambetter

Policy updates include:

  • Clarified DTC be recurrent, advanced or metastatic per NCCN
  • Removed lung cancer indication as it now carries a NCCN category 2B rating

 

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.