Specialty medical injectable drug program updates

Specialty medical injectable drug programs have recently changed. Please review the following table to learn more.

Drug Name Effective Date UHC Commercial Treatment Uses Summary of Changes

Long Acting Colony Stimulating Factors Drug Class

(Neulasta®,

Udenyca®,

Ziextenzo®,

Fulphila®,

Nyvepria™)

Jan. 1, 2021 X For supportive treatment of oncology chemotherapy protocols.
  • Add notification/prior authorization for Nyvepria.
  • For UHC Commercial plans, preferred products: Neulasta & Ziextenzo. 
Scenesse® Jan. 1, 2021 X Scenesse is a melanocortin 1 receptor (MC1-R) agonist indicated to increase pain free light exposure in adult patients with a history of phototoxic reactions from erythropoietic protoporphyria (EPP).
  • Add notification/ prior authorization requirement.

Tecartus™

(CAR-T Cell Therapy)

Jan. 1, 2021 X Cellular therapy treatment for Mantle Cell Lymphoma (MCL).
  • Add notification/ prior authorization requirement.
  • Coverage reviews will be managed by Optum Transplant Resource Services.
Uplizna™ Jan. 1, 2021 X Treatment for neuromyelitis optica spectrum disorder (NMOSD) in adult patients who are anti-aquarporin-4 (AQP4) antibody positive.
  • Add notification/ prior authorization requirement.
  • For UHC Commercial plans, Site of Care review will be conducted.
Viltepso™ Jan. 1, 2021 X For the treatment of Duchenne muscular dystrophy (DMD) in patients with a mutation of the DMD gene that is amenable to exon 53 skipping.
  • Add notification/ prior authorization requirement.
  • For UHC Commercial plans, Site of Care review will be conducted.

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.

Specialty Medical Injectable Drug Program updates: Moving to biosimilars for Rituxan®

Biosimilars create a more competitive pricing environment among drug manufacturers that can help drive down drug costs and the continued development of new biosimilar medications is a key factor in long-term specialty cost management. UnitedHealthcare strives to provide coverage for biosimilars whenever possible to ensure a robust pipeline of future products. Each innovator (original biologic) and its biosimilar are evaluated one by one and when financially supportable, we prefer the biosimillar.

Effective Oct. 1, 2020, for UnitedHealthcare commercial plans, Rituxan, the innovator brand, will no longer be preferred for members new to therapy. RuxienceTM and Truxima®, the biosimilars, will now be the preferred products for members new to therapy. With this change, members will need to have tried both Ruxience and Truxima, prior to the use of Rituxan or Rituxan Hycela. These updates apply to oncology and non-oncology uses. UnitedHealthcare will honor all approved prior authorizations on file until the end date on the authorization or the date the member’s eligibility changes.

Innovator Brand Biosimilar Brand(s) Administration method Benefit UHC Commercial Preferred Product 10/1/20
Rituxan

Ruxience

Truxima

Physician administered Medical

Ruxience

Truxima

Please contact your broker or UnitedHealthcare representative for more information.

Footnotes

Note: Certain specialty medical injectable drug programs and updates will not be implemented for providers practicing in Rhode Island, with respect to certain commercial members, until reviewed and approved by the Rhode Island Office of Health Insurance Commissioner (OHIC). UnitedHealthcare encourages providers practicing in Rhode Island to call in to confirm if prior authorization is required. This exception does not apply to Medicaid and Medicare.