UnitedHealthcare medical drug benefit prior authorization update effective July 1, 2019

Summary

  • Ultomiris™ (ravulizumab) — The U.S. Food and Drug Administration (FDA) recently approved Ultomiris as a treatment for paroxysmal nocturnal hemoglobinuria (PNH), a rare blood disorder.
  • Rebinyn® — The FDA recently approved Rebinyn for use in adults and children with hemophilia B for the on-demand treatment of acute bleeding episodes and for the perioperative management of bleeding.
  • Fibryga® The FDA recently approved Fibryga for the treatment of acute bleeding episodes in patients with congenital fibrinogen deficiency, including afibrinogenemia and hypofibrinogenemia.
  • Neulasta Onpro® and Neulasta® These drugs are in a class called Long Acting Granulocyte Colony Stimulating Factors.  They are used as the standard of care for decreasing the incidence of febrile neutropenia in select patients receiving chemotherapy.

Effective July 1, 2019, the White Blood Cell Colony Stimulating Factors medical drug policy will be updated to include preferred product coverage criteria. For pegfilgrastim, Neulasta Onpro and Neulasta will be the preferred products under the medical benefit. In addition, there will be aligned strategies and Neulasta will be the covered product under the pharmacy benefit starting Jan. 1, 2020.  For the drug policy, preferred product language will be added as follows:

  • Use of Neulasta Onpro and Neulasta vial prior to the coverage of Fulphila and Udenyca.

In addition to the preferred product changes to the drug policy, UnitedHealthcare commercial plans will be expanding the current prior authorization requirements on these medications to include use for any diagnosis.

  • Neulasta Onpro/Neulasta, Fulphila, and Udenyca currently require prior authorization when used to treat a cancer diagnosis. 
  • On July 1, 2019, for UnitedHealthcare commercial plans (including affiliated plans for Oxford, UMR and Neighborhood Health Partnership) use of these medications for all diagnoses will require prior authorization with this policy change. 
  • On Aug. 1, 2019, for affiliate plans UnitedHealthcare of the Mid-Atlantic and UnitedHealthcare of the River Valley, use of these medications for all diagnoses will require prior authorization.

For UnitedHealthcare commercial members, current authorizations will be honored through their end date. Upon authorization renewal, the updated policy will apply. Care providers are encouraged to begin using the preferred Colony Stimulating Factor products.

If you administer any of these medications without first completing the notification/prior authorization process, the claim may be denied. Members can’t be billed for services denied due to failure to complete the notification/prior authorization process.

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

For dates of service on or after July 1, 2019, UnitedHealthcare will require notification/prior authorization for Ultomiris, Rebinyn and Fibryga. Ultomiris has also been added to the Review at Launch Medication List for UnitedHealthcare Commercial Plans and Community Plans. For UnitedHealthcare Commercial Plans only, if Ultomiris is requested in the outpatient hospital setting, this site of care will be reviewed for medical necessity.