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Effective September 16, 2020: Pharmacy and Biopharmacy Policies

Date: 09/11/20

Superior HealthPlan has introduced new or revised pharmacy and/or 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 have been revised or added:

  • Aclidinium/Formoterol (Duaklir Pressair) (CP.PCH.23)
  • Afamelanotide (Scenesse) (CP.PHAR.444)
  • Blinatumomab (Blincyto) (CP.PHAR.312)
  • Brexpiprazole (Rexulti) (CP.PMN.68)
  • Burosumab-twza (Crysvita) (CP.PHAR.11)
  • Cinacalcet (Sensipar) (CP.PHAR.61)
  • Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (CP.PHAR.385)
  • Daratumumab, Daratumumab-Hyaluronidase-fihj (Darzalex, Darzalex Faspro) (CP.PHAR.310)
  • Deferoxamine (Desferal) (CP.PHAR.146)
  • Dichlorphenamide (Keveyis) (CP.PCH.04)
  • Elexacaftor-ivacaftor-tezacaftor (Trikafta) (CP.PHAR.440)
  • Entrectinib (Rozlytrek) (CP.PHAR.441)
  • Erdafitinib (Balversa) (CP.PHAR.423)
  • Erlotinib (Tarceva) (CP.PHAR.74)
  • Everolimus (Afinitor, Afinitor Disperz, Zortress) (CP.PHAR.63)
  • Fulvestrant (Faslodex Injection) (CP.PHAR.424)
  • Givosiran (Givlaari) (CP.PHAR.457)
  • Glecaprevir/Pibrentasvir (Mavyret) (HIM.PA.SP36)
  • GLP-1 receptor agonists (CP.PMN.183)
  • Ipilimumab (Yervoy) (CP.PHAR.319)
  • Ixazomib (Ninlaro) (CP.PHAR.302)
  • Leuprolide Acetate (Lupron, Lupron Depot, Eligard, Lupaneta Pack, Fensolvi) (CP.PHAR.173)
  • Lidocaine transdermal (Lidoderm, ZTlido) (CP.PMN.08)
  • Luspatercept-aamt (Reblozyl) (CP.PHAR.450)
  • Neratinib (Nerlynx) (CP.PHAR.365)
  • Netupitant and Palonosetron (Akynzeo), Fosnetupitant and Palonosetron (Akynzeo IV) (CP.PMN.158)
  • Nintedanib (Ofev) (CP.PHAR.285)
  • Nivolumab (Opdivo) (CP.PHAR.121)
  • Obeticholic Aacid (Ocaliva) (CP.PHAR.287)
  • Obeticholic Aacid (Ocaliva) (CP.PHAR.287)
  • Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa) (CP.PHAR.40)
  • Olaparib (Lynparza) (CP.PHAR.360)
  • Palbociclib (Ibrance) (CP.PHAR.125)
  • Palivizumab (Synagis) (CP.PHAR.16)
  • Paricalcitol Injection (Zemplar) (CP.PHAR.270)
  • Pembrolizumab (Keytruda) (CP.PHAR.322)
  • Pomalidomide (Pomalyst) (CP.PHAR.116)
  • Quetiapine ER (Seroquel XR) (CP.PMN.64)
  • Ramucirumab (Cyramza) (CP.PHAR.119)
  • Rucaparib (Rubraca) (CP.PHAR.350)
  • Sargramostim (Leukine) (CP.PHAR.295)
  • Selinexor (Xpovio) (CP.PHAR.431)
  • SGLT2 inhibitors (HIM.PA.91)
  • Sofosbuvir/Velpatasvir (Epclusa) (HIM.PA.SP1)
  • Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi) (HIM.PA.SP63)
  • Tadalafil BPH - ED (Cialis) (CP.PMN.132)
  • Tazemetostat (Tazverik) (CP.PHAR.452)
  • Teprotumumab (Tepezza) (CP.PHAR.465)
  • Tesamorelin (Egrifta SV) (CP.PHAR.109)
  • Tolvaptan (Jynarque, Samsca) (CP.PHAR.27)
  • Topical Acne Treatment (HIM.PA.71)
  • Trifarotene (Aklief) (CP.PMN.225)
  • Ubrogepant (Ubrelvy) (CP.PHAR.476)
  • Umeclidinium/Vilanterol (Anoro Ellipta) (HIM.PA.106)
  • Vigabatrin (Sabril) (CP.PHAR.169)
  • Vorinostat (Zolinza) (CP.PHAR.83)
  • Vortioxetine (Trintellix) (CP.PMN.65)

To review new policy overviews or updated policy revisions, please visit: Effective September 16, 2020: Pharmacy and Biopharmacy Policies

To review all pharmacy policies, please visit Superior’s Clinical 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.