Prior authorization updates for Gamifant®, Revcovi™ and Administrative Guide updates for Synojoynt™

UnitedHealthcare prior authorization updates for Gamifant®, Revcovi™ to be effective April 1, 2019 

The following medications covered under the medical benefit will require prior authorization effective April 1:

  • Gamifant (emapalumab-lzsg) – Approved for the treatment of pediatric and adult patients with a rare condition called primary hemophagocytic lymphohistiocytosis (HLH) disease, who are not responding to conventional treatment. Gamifant has been added to the Review at Launch Program.
  • Revcovi (elapegademase-lvlr) – Approved for the treatment of adenosine deaminase severe combined immune deficiency (ADA- SCID) in pediatric and adult patients. As part of the prior authorization review, site of care will also be evaluated. Revcovi has also been added to the Review at Launch Program.

The notification/prior authorization requirement for Gamifant and Revcovi will apply to all UnitedHealthcare commercial plans including affiliate plans such as UnitedHealthcare of the Mid-Atlantic, UnitedHealthcare of the River Valley, UnitedHealthcare Oxford, UMR, and Neighborhood Health Partnership.

Updates to the Administrative Guide protocol for Synojoynt 

  • Approved for the treatment of osteoarthritis of the knee in patients who have failed conservative treatments such as physical therapy and simple pain medicines, this product enters an already crowded class of sodium hyaluronate products.
  • Beginning April 1, 2019, UnitedHealthcare will require that Synojoynt be acquired from a designated specialty pharmacy for members covered by UnitedHealthcare commercial plans, as part of our Administrative Guide protocol. This is the same process currently required for acquisition of Gel-one®, Supartz®, Hyalgan®, Orthovisc®, Gel-Syn®, Gelsyn-3®, Genvisc®, Durolane®, Trivisc and Hymovis®. These requests may be subject to medical policy review as part of benefit coverage review. In addition, Mid-Atlantic Health Plan, Neighborhood Health Partnership, UnitedHealthcare of the River Valley and Oxford Health Plans (CT and NJ) will require prior authorization/pre-certification for Synojoynt in all places of service for our commercial members beginning April 1, 2019. 

An enhancement to the prior authorization program 

  • C-Codes- UnitedHealthcare commercial plans will begin to enforce prior authorization/notification requirements for temporary C-codes beginning April 1, 2019. The Centers for Medicare & Medicaid Services (CMS) utilizes temporary C codes to report drugs and biologicals that must be used by OPPS (outpatient prospective payment system) facilities when no other HCPCS code is assigned.  For injectable medications that require notification/prior authorization, all HCPC and CPT codes related to the drug require notification/prior authorization, even when unclassified codes (J3490, J3590, or C9399) or temporary C-codes need to be used. This change aligns our commercial plans with correct coding requirements already in place for Medicaid and Medicare.