Specialty medical injectable drug program, requirements and drug policy updates
Updates to prior authorizations for bleeding disorder medications and for voluntary requests for pre-determination; updates to the oncology specialty pharmacy requirement for commercial plan members.
Review the following table to determine changes to our specialty medical injectable drug programs.
Specialty medical injectable drugs added to review at launch
|Drug Name||UnitedHealthcare Commercial||Treatment Uses|
|Briumvi™ (ublituximab-xiiy)||X||Indicated for the treatment of relapsing forms of multiple sclerosis, to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults.|
|Leqembi™ (lecanemab-irmb)||X||Indicated for the treatment of Alzheimer's disease in patients with mild cognitive impairment or mild dementia stage of disease.|
|Rebyota™ (fecal microbiota, live-jslm)||X||Indicated for the prevention of recurrence of Clostridioides difficile (C.diff) infection in individuals 18 years of age and older, following antibiotic treatment for recurrent C. diff infection.|
|Sunlenca® (lenacapavir)||X||Indicated for the treatment of HIV-1 infection in heavily treatment-experienced adults with multidrug resistant HIV-1 infection failing their current antiretroviral regimen due to resistance, intolerance, or safety considerations.|
For details, please review the UnitedHealthcare Commercial Plan Review at Launch Medication List.
Updates for UnitedHealthcare prior authorizations for bleeding disorder medications and for voluntary requests for pre-determination
Effective April 1, 2023, Optum, an affiliate company of UnitedHealthcare, will start managing prior authorization requests from providers seeking medical benefit coverage for medications used to treat bleeding disorders, such as factor products, for UnitedHealthcare commercial plan members. Providers seeking coverage for members that self-administer their bleeding disorders medication should contact the member’s pharmacy benefit manager for coverage questions.
In addition, the process for requesting pre-determination for medications covered under the medical benefit will also be moving to Optum. A pre-determination is a voluntary request for benefit coverage review for a medication or service that does not require prior authorization.
Requesting prior authorizations or pre-determinations using the Specialty Guidance Program tool in the UnitedHealthcare Provider Portal is designed to reduce the turnaround time for a determination by leveraging auto-decisioning technology that results in over 50%1 of all prior authorization cases approved in real time. The system will document clinical requirements, as applicable, during the intake process and prompt you to provide responses to the clinical criteria questions.
Learn more about the Specialty Guidance Program.
Updates to the oncology specialty pharmacy requirement for commercial plan members
Effective for dates of service on or after Feb. 1, 2023, the medication sourcing requirement for the following oncology supportive care medications will no longer apply for outpatient hospital providers. The drugs still require prior authorization per the Enterprise Prior Authorization List:
|Drug Name||HCPG Code|
Learn more about the Specialty Pharmacy Requirements — UnitedHealthcare Commercial Plans.
For questions, please contact your broker or UnitedHealthcare representative.