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.
