Specialty medical injectable drug program, requirements and drug policy updates

New specialty medical injectable updates and requirements announced.


Review the following tables 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
Elevidys
(delandistrogene moxeparvovec-rokl)
X Gene therapy used for the treatment of Duchenne muscular dystrophy in ambulatory pediatric patients aged 4 through 5.
Roctavian™
(valoctocogene roxaparvovec-rvox)
X Gene therapy for the treatment of adults with hemophilia A – an inherited genetic disorder caused by insufficient levels of the clotting protein, factor VIII.
Vyjuvek™ 
(beremagene geperpavec-svdt)
X Used for the treatment of wounds in patients 6 months of age and older with dystrophic epidermolysis bullosa.
Vyvgart® Hytrulo 
(efgartigimod alfa and hyaluronidase-qvfc)
X Used for the treatment of generalized myasthenia gravis (gMG) in adult patients who are anti-acetylcholine receptor (AChR) antibody positive.

Review the UnitedHealthcare Commercial Plan Review at Launch Medication List.

For questions, please contact your broker or UnitedHealthcare representative.

SPECIALTY MEDICAL INJECTABLE DRUGS ADDED TO MEDICAL BENEFIT THERAPEUTIC EQUIVALENT MEDICATIONS – EXCLUDED DRUGS

For UnitedHealthcare commercial business effective October 1, 2023

Therapeutic Class Excluded Medications Other Options
VEGF

Beovu®,

Byooviz™ (Lucentis biosimilar)

Avastin®, Eylea®, Lucentis®, Cimerli™ (Lucentis biosimilar), Vabysmo®
Immune Globulin Cuvitru™ Bivigam®, Carimune®, Flebogamma®, Gammagard®, Gammaked™, Gammaplex®, Gamunex-C®, Hizentra®, Hyqvia™, Octagam®, Privigen®>, Xembify®

SPECIALTY MEDICAL INJECTABLE DRUGS ADDED TO MEDICATION SOURCING FOR OUTPATIENT HOSPITALS

For UnitedHealthcare commercial business effective October 1, 2023

Therapeutic Class Therapeutic Class HCPC Code(s) Specialty Pharmacy
Beovu® VEGF Q5124

To be determined

Briumvi™ Multiple Sclerosis J2329

To be determined

Byooviz™ VEGF J0179

To be determined

Elevidys* Gene Therapy J3490, J3590, C9399

To be determined

Lamzede® Enzyme Replacement Therapy J3490, J3590, C9399 Eversana
Qalsody™ CNS Agents J3490, J3590, C9399 Optum Frontier Pharmacy
Syfovre™ Complement Inhibitors – Ophthalmologic use

C9151

To be determined

Vyjuvek™*

Gene Therapy

J3490, J3590, C9399

To be determined

Review the UnitedHealthcare Commercial Plan Medication Sourcing List.

For questions, please contact your broker or UnitedHealthcare representative.

 

UPDATES TO DRUG PROGRAM REQUIREMENTS AND DRUG POLICIES

For UnitedHealthcare commercial business effective October 1, 2023

Drug Name Treatment Uses

Summary of Changes

Altuviiio™
(antihemophilic factor (recombinant), Fc-VWF-XTEN fusion protein-ehtl)
Used for routine prophylaxis and on-demand treatment to control bleeding episodes, as well as perioperative management (surgery) for adults and children with hemophilia A. Add notification/prior authorization
Briumvi™
(ublituximab-xiiy)
Used for the treatment of adults with relapsing forms of multiple sclerosis (MS). Add notification/prior authorization
Elevidys
(delandistrogene moxeparvovec-rokl)
Gene therapy used for the treatment of Duchenne muscular dystrophy in ambulatory pediatric patients age 4 through 5. Add notification/prior authorization
Lamzede®
(velmanase alfa-tycv)
Used for the treatment of non-central nervous system manifestations of alpha-mannosidosis in adult and pediatric patients. Add notification/prior authorization in outpatient place of service and Site of Care
Qalsody™
(tofersen)
Used for the treatment of amyotrophic lateral sclerosis (ALS) in adults who have a mutation in the superoxide dismutase 1 (SOD1) gene. Add notification/prior authorization
Syfovre™
(pegcetacoplan injection)
Used for the treatment of geographic atrophy (GA) secondary to age-related macular degeneration (AMD). Add notification/prior authorization
Vyjuvek™
(beremagene geperpavec-svdt)
Used for the treatment of dystrophic epidermolysis bullosa (DEB) in pediatric and adult patients Add notification/prior authorization and Site of Care

Upon prior authorization renewal, the updated policy will apply. UnitedHealthcare will honor all approved prior authorizations on file until the end date on the authorization or the date the member’s eligibility changes. Providers don’t need to submit a new notification/prior authorization request for members who already have an authorization for these medications on the effective date noted above.

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