Requirement updates for specialty medical injectable drugs

Specialty medical injectable drug requirements have recently changed. Please review the following tables to learn more about added drugs and updates to notification/prior authorization requirements.

Specialty medical injectable drugs added to Review at Launch Program
Drug Name Treatment Uses

Avsola™

(infliximab-axxq)

For the treatment of Crohn’s disease, ulcerative colitis, rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis and plaque psoriasis.
Vyepti™ (eptinezumab-jjmr) For the prevention of migraine headache.
Monoferric – IV Iron

For the treatment of iron deficiency anemia in adult patients who have an intolerance to or are unresponsive to oral iron therapy..
Tepezza (teprotumumab-trbw) For the treatment of thyroid eye disease.

For more information and a complete list, download the UnitedHealthcare Commercial Plan Review at Launch Medication List

Updates to Drug Program Requirements and Drug Policies

All codes that would be used to bill for these medications will require prior authorization, including any Q or C codes that the Centers for Medicare & Medicaid Services (CMS) may assign to this medication.

Updates to specialty medical injectable drugs
Drug Policy Name Effective Date Treatment Uses Summary of Changes

Adakveo® (crizanlizumab-tmca)

July 1, 2020

Adakveo is indicated to reduce the frequency of vasoocclusive crises (VOCs) in adults and pediatric patients aged 16 years and older with sickle cell disease.
  • Require notification/ prior authorization.
  • For UHC Commercial plans, Site of Care Review will be conducted.

Givlaari™

(givosiran)

July 1, 2020

Givlaari is for the treatment of acute hepatic porphyria (AHP) in adult patients.
  • Require notification/ prior authorization.
  • For UHC Commercial plans, Site of Care Review will be conducted.

Vyondys 53™

(golodirsen)

July 1, 2020

Vyondys 53 is used for the treatment of Duchenne muscular dystrophy (DMD).
  • Require notification/ prior authorization.
  • For UHC Commercial plans, Site of Care Review will be conducted.

Inflammatory Expansion

(Actemra®

Avsola™

Benlysta®

Entyvio®

Cimzia®

Inflectra®

Orencia®

Remicade®

Simponi®/ Simponi Aria®

Stelara®)

July 1, 2020 The inflammatory biologics are indicated for the treatment of various inflammatory diseases such as rheumatoid arthritis, psoriasis, and inflammatory bowel diseases.
  • This class currently requires notification/prior authorization, including site of care reviews. We will expand the prior authorization requirement to all outpatient places of service for all drugs in the class.
  • Adding prior authorization and site of care review to Avsola, a non-preferred infliximab product. Avsola was also added to review at launch.
Ziextenzo® (pegfilgrastim-bmez) July 1, 2020

Ziextenzo is used to decrease the incidence of infection in patients receiving myelosuppressive chemotherapy.
  • Require prior authorization.
  • Ziextenzo will be a non-preferred product. The preferred pegfilgrastim product is Neulasta. 

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 do not 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.

Note: Certain specialty medical injectable drug program updates will not be implemented for providers practicing in Rhode Island until reviewed and approved by the Rhode Island Office of Health Insurance Commissioner (OHIC).