Specialty medical injectable drug program, requirements and drug policy updates for October
New specialty medical injectable updates and requirements announced October 2023.
Please review the following tables to determine changes to our specialty medical injectable drug programs.
Specialty medical injectable drugs added to review at launch
For UnitedHealthcare Commercial business
| Drug Name | Treatment Uses |
|---|---|
| Eylea HD® (aflibercept) |
Used for the treatment of neovascular age-related macular degeneration, diabetic macular edema, and diabetic retinopathy. |
| Veopoz™ (pozelimab-bbfg) |
Used for the treatment of adult and pediatric patients 1 year of age and older with CHAPLE disease. |
Download 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 January 1, 2024
| Excluded Medication | Therapeutic Class | HCPCS Code(s) | Suggested Alternatives |
|---|---|---|---|
| Elfabrio® | Enzyme Replacement Therapy | J3490, J3590, C9399 | Fabrazyme® |
Specialty medical injectable drugs added to medication sourcing for all outpatient providers
For UnitedHealthcare Commercial business
| Drug Name | Effective Date | Therapeutic Class | HCPCS Code(s) | Specialty Pharmacy |
|---|---|---|---|---|
| Elevidys | 10/1/23 | Gene Therapy |
J3490, J3590, C9399 | Optum Frontier Therapies |
| Vyjuvek™ | 10/1/23 | Gene Therapy |
J3490, J3590, C9399 | Option Care Health |
| Roctavian® | 10/1/23 | Gene Therapy |
J3490, J3590, C9399 | Please contact UHC Provider Services at the number on the back of the member ID card for available options |
Specialty medical injectable drugs added to medication sourcing for outpatient hospital providers only
For UnitedHealthcare Commercial business effective October 1, 2023
| Drug Name | Effective Date | Therapeutic Class | HCPCS Code(s) | Specialty Pharmacy |
|---|---|---|---|---|
| Beovu®1 | 10/1/23 | VEGF |
Q5124 | Accredo Health Group, Optum Pharmacy (Specialty) |
| Briumvi® | 10/1/23 | Multiple Sclerosis |
J2329 | Kroger Specialty Pharmacy, Option Care Health, Optum Pharmacy (Specialty) |
| Byooviz™1 | 10/1/23 | VEGF |
J0179 | Kroger Specialty Pharmacy |
| Syfovre™ | 10/1/23 | Complement Inhibitors – Ophthalmologic use | J2781 | Optum Pharmacy (Specialty) |
| Elfabrio®1 | 1/1/24 | Enzyme Replacement Therapy | J3490, J3590, C9399 | Eversana |
| Izervay™ | 1/1/24 | Complement Inhibitors – Ophthalmologic use | J3490, J3590, C9399 | To be determined |
| Rystiggo® | 1/1/24 | Central Nervous System agents | J3490, J3590, C9399 | PANTHERx Rare Pharmacy |
| Veopoz® | 1/1/24 | Blood Modifying agents | J3490, J3590, C9399 | Orsini |
| Vyvgart® Hytrulo | 1/1/24 | Central Nervous System agents | J3490, J3590, C9399 | Option Care Health |
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 January 1, 2024
| Drug Name | Treatment Uses | Summary of Changes |
|---|---|---|
| Izervay™ (avacincaptag pegol) |
Used for the treatment of geographic atrophy secondary to age-related macular degeneration. | VEGF |
| Roctavian™ (valoctocogene roxaparvovec-rvox) |
Used for the treatment of adults with severe hemophilia A. | Multiple Sclerosis |
| Rystiggo® (rozanolixizumab-noli) |
Used for the treatment of generalized myasthenia gravis in adult patients who are anti-acetylcholine receptor or anti-muscle-specific tyrosine kinase antibody positive. | VEGF |
| Veopoz™ (pozelimab-bbfg) |
Used for the treatment of adult and pediatric patients 1 year of age and older with CHAPLE disease. | Complement Inhibitors – Ophthalmologic use |
| Vyvgart® Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) |
Used for the treatment of generalized myasthenia gravis in adult patients who are anti-acetylcholine receptor antibody positive. | Enzyme Replacement Therapy |
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.
For questions, please contact your broker or UnitedHealthcare representative.
