Effective September 1, 2023: Pharmacy and Biopharmacy Policies

Date: 06/28/23

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 September 1, 2023, at 12:00AM.

POLICY	APPLICABLE PRODUCTS	NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS
Omaveloxolone (Skyclarys) (CP.PHAR.590)	Ambetter	Policy updates include: Revised dosing Added requirement for left ventricular ejection fraction ≥ 40%, and no history of clinically significant left-sided heart disease or clinically significant cardiac disease per package insert and study protocol; Added exclusion for pes cavus as it did not result in statistically significant improvement in mFARS in the MOXIe studies
Biologic and Non-biologic DMARDs (HIM.PA.SP60)	Ambetter	Policy updates include: For Actemra, revised criteria for COVID-19 emergency authorized use to FDA-approved indication; For ankylosing spondylitis, polyarticular juvenile idiopathic arthritis, plaque psoriasis, psoriatic arthritis, rheumatoid arthritis, Crohn’s disease, and ulcerative colitis, added TNFi criteria to allow bypass if member has had history of failure of two TNF blockers; references reviewed and updated. For psoriatic arthritis, updated criteria from “Xeljanz/Xeljanz XR or Rinvoq” to “Xeljanz/Xeljanz XR and Rinvoq” to align with commercial policy and to allow trial of both JAK inhibitors after trial of TNF-blockers. For Kevzara, added criteria for newly approved polymyalgia rheumatica indication to policy and added Appendix O for polymyalgia rheumatica Classification Criteria Scoring Algorithm; For Amjevita, updated FDA approved indications to reflect new hidradenitis suppurativa indication, added Amjevita to hidradenitis suppurativa criteria, updated biosimilar dosing in section V, and added 10 mg/0.2 mL prefilled glass syringe dosage form; For plaque psoriasis, corrected Otezla misspelling for “request is for Otezla” criteria.

POLICY

APPLICABLE PRODUCTS

NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS

Omaveloxolone (Skyclarys) (CP.PHAR.590)

Ambetter

Policy updates include:

Revised dosing
Added requirement for left ventricular ejection fraction ≥ 40%, and no history of clinically significant left-sided heart disease or clinically significant cardiac disease per package insert and study protocol;
Added exclusion for pes cavus as it did not result in statistically significant improvement in mFARS in the MOXIe studies

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

Ambetter

Policy updates include:

For Actemra, revised criteria for COVID-19 emergency authorized use to FDA-approved indication;
For ankylosing spondylitis, polyarticular juvenile idiopathic arthritis, plaque psoriasis, psoriatic arthritis, rheumatoid arthritis, Crohn’s disease, and ulcerative colitis, added TNFi criteria to allow bypass if member has had history of failure of two TNF blockers; references reviewed and updated.
For psoriatic arthritis, updated criteria from “Xeljanz/Xeljanz XR or Rinvoq” to “Xeljanz/Xeljanz XR and Rinvoq” to align with commercial policy and to allow trial of both JAK inhibitors after trial of TNF-blockers.
For Kevzara, added criteria for newly approved polymyalgia rheumatica indication to policy and added Appendix O for polymyalgia rheumatica Classification Criteria Scoring Algorithm;
For Amjevita, updated FDA approved indications to reflect new hidradenitis suppurativa indication, added Amjevita to hidradenitis suppurativa criteria, updated biosimilar dosing in section V, and added 10 mg/0.2 mL prefilled glass syringe dosage form;
For plaque psoriasis, corrected Otezla misspelling for “request is for Otezla” criteria.

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.