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Effective November 1, 2026: Pharmacy and Biopharmacy Policies
Effective date
Nov 1, 2026
Identified
Aug 26, 2026
Summary
Ambetter, Ambetter Health and Superior HealthPlan (Medicaid) added, updated or retired pharmacy and biopharmacy policies, effective November 1, 2026 at 12:00 AM. The changes include revised medical necessity review criteria for drugs such as Hemlibra, Tepezza, Lumvoa, Journavx, Skyrizi and Tofidence, a quantity limit of 29 tablets per 14 days per course of treatment for Journavx (suzetrigine), and an added HCPCS code Q5164. The notice also says Beqvez and Roctavian are retired and no longer commercialized.
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What to do
Action · 2 steps
01Already effective November 1, 2026: Check the current criteria for the drugs listed, such as Journavx (suzetrigine) with its quantity limit of 29 tablets per 14 days per course of treatment, before submitting medical necessity requests.
02For questions, contact Centene Pharmacy Services at 1-866-768-7147, and review all policies on Superior's Clinical, Payment & Pharmacy Policies webpage.
Codes mentioned
Q5164
Original notice
Effective November 1, 2026: Pharmacy and Biopharmacy Policies
ambetterhealth.com · Always check the source before changing claims.
Related changes
See all Ambetter changes →Upcoming Changes to Pharmacy Policies (PDF)MediumEffective Nov 1, 2026 · PharmacyUpcoming Changes to Pharmacy Policies.MediumEffective Nov 1, 2026 · PharmacyEffective November 1, 2026: Pharmacy and Biopharmacy PoliciesMediumEffective Nov 1, 2026 · PharmacyEffective November 1, 2026: Pharmacy and Biopharmacy PoliciesMediumEffective Nov 1, 2026 · PharmacyBrowse every Ambetter change in the policy list