New Pharmacy Policies for Ambetter As of January 3rd


Effective January 3, 2022: Pharmacy and Biopharmacy Policies 

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 January 3, 2022 at 12:00AM.

Changes in these policies reflect pre authorization requirement amendments that are less burdensome to insureds, physicians, or health care providers.


  • Bevacizumab

    • Product - Medicaid 

    • Policy updates include - Updated with Mvasi’s FDA-approved indications of epithelial ovarian, fallopian tube, or primary peritoneal cancers 

  • Isatuximab-irfc 

    • Product - Medicaid

    • Policy updates include - Criteria added for FDA approved indication: combination use with carfilzomib and dexamethasone for relapsed or refractory MM after 1 to 3 prior lines of therapy

  • Lacosamide 

    • Product - Medicaid 

    • Policy updates include - Policy updated to reflect newly FDA-approved pediatric age extension down to 1 month of age for partial-onset seizures 

  • Osimertinib

    • Product - Ambetter

    • Policy updates include - Removed oncologist prescribing requirement 

  • Pembrolizumab

    • Product - Medicaid, CHIP, and Ambetter 

    • Policy updates include - Criteria added for the new FDA approved indication: adjacent treatment of RCC 

  • Rituximab 

    • Product - Medicaid, CHIP, and Ambetter 

    • Policy updates include - For Ruxience updated FDA approved indications to include RA per updated prescribing information 

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