https://www.superiorhealthplan.com/newsroom/july-2020-new-drugs-requiring-utilization-management.html

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July 2020: New Drugs Requiring Utilization Management

Date:06/30/20

Superior HealthPlan is committed to keeping providers updated on prescription drugs as they enter the market, whether or not they will need prior authorization, as well as how these drugs may be billed. Upon approval from the U.S. Food and Drug Administration (FDA) and/or availability onto the market, and if determined by Superior that the drug will be a covered benefit, these drugs will be subjected to utilization management. This can include, but is not limited to clinical prior authorization, quantity limit and age limit or specialty pharmacy.

Depending on the formulation/route of administration of the drug, the drug may be billed under the pharmacy benefit or medical benefit as a Clinician Administered Drug (CAD). CADs are billed using a Healthcare Common Procedure Coding System (HCPCS) J Code. Most CAD drugs, upon FDA approval, will not have a specific J Code assigned. Instead, they will fall under the miscellaneous J Code (J3590) until they are officially assigned their own J Code.

For July, the following drugs will be subjected to utilization management:

	DRUG NAME BRAND (GENERIC)	ROUTE OF ADMINISTRATION	INDICATION
1	Fensolvi (leuprolide acetate)	Subcutaneous	Central Precocious Puberty
2	Retevmo (selpercatinib)	Oral	Cancer
3	Qinlock (ripretinib)	Oral	Gastrointestinal Stromal Tumor
4	artesunate	Intravenous	Malaria
5	naxitamab	Intravenous	Cancer
6	givinostat	Oral	Duchene’s Muscular Dystrophy
7	Nyvepria (pegfilgrastim-apgf)	Subcutaneous	Neutropenia
8	Recarbrio (imipenem/cilastin/relebactam)	Intravenous	Antibiotic
9	Revascor (rexlemestrocel-L)	Intramyocardial Injection	Chronic Heart Failure
10	valoctocogene roxaparvovec	Intravenous	Hemophilia A
11	Ryoncil (remestemcel-L)	Intravenous	Acute graft vs. host disease
12	KTE-X19	Intravenous	Mantle Cell Lymphoma
13	lisocabtagene maraleucel	Intravenous	Non-Hodgkin's Lymphoma
14	oxymetazoline	Ophthalmic Solution	Blepharoptosis
15	Viaskin Peanut	Transdermal Patch	Peanut Allergy
16	veverimer	Oral	Chronic Kidney Disease (CKD)
17	Winlevi (clascoterone)	Topical	Acne
18	viloxazine	Oral	ADHD
19	cantharidin	Topical	Molluscum Contagiosum
20	Gimoti (metoclopramide)	Nasal Spray	Diabetic Gastroparesis
21	Fintelpa (fenfluramine)	Oral	Dravet Syndrome
22	Phesgo (pertuzumab/trastuzumab/hyaluronidase-zzxf)	Subuctaneous	Breast Cancer

Please note:Some of the drugs listed above are billed under the medical benefit. To determine which of these drugs under the medical benefit will need prior authorization, please utilizeSuperior’s Pre-Auth Needed Tool.

For detailed information regarding utilization management, including prior authorization criteria and quantity limits, please visitSuperior’s Pharmacy webpage. For information regarding utilization management for Ambetter from Superior HealthPlan, please referenceAmbetter’s 2020 Prescription Drug List.

For questions regarding any of the drugs listed above and utilization management or prior authorization for these drugs, please contact the Superior Pharmacy Department at 1-800-218-7453, ext. 22080.