Updates to specialty medical injectable drug requirements

Specialty medical injectable drug added to review at launch program

Since certain new drugs are added periodically by UnitedHealthcare, providers are recommended to request pre-service coverage reviews for medications listed on UnitedHealthcare’s Review at Launch Commercial and Community Plan Medication Lists.

Clinical coverage reviews can also help avoid starting a patient on therapy that may later claim denials due to lack of medical necessity. Claims may be denied if a pre-service coverage review is not completed.

List of newly added speciality medical injectable drugs
Drug Name Treatment Uses
Xembify® Treatment of primary humoral immunodeficiency (PI) inpatients 2 years of age and older.

Changes to notification/prior authorization

The notification/prior authorization requirement for the medications listed below 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. 

If a provider administers 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.

Medications requiring notification/prior authorization
Drug Name Effective Date Treatment Uses Summary of Changes
OSynagis® (palivi-zumab) Oct. 1, 2019 Respiratory syncytial virus (RSV) prophylaxis.

Removed PA requirement from affiliate plans UnitedHealthcare of the Mid- Atlantic, Inc., UnitedHealthcare of the River Valley and Neighborhood Health Partnership. Administrative guide drug sourcing requirements remain in place. 

Botulinum Toxins A and B (Dysport®, Xeomin®,
Botox®, 
Myobloc®)
Oct. 1, 2019 Cervical dystonia, migraine, spasticity, blepharospasm, chronic sialorrhea, and certain other disorders of muscle tone. Removed PA requirement from affiliate plans UnitedHealthcare of the Mid- Atlantic, Inc., UnitedHealthcare of the River Valley and Neighborhood Health Partnership. Administrative guide drug sourcing requirements remain in place. 
Anemia Drugs Oct. 1, 2019 Used to treat anemia. Removed PA requirement from Neighborhood Health Partnership for the following codes: J0881; J0882; J0885; J0887; J0888; J0890.
Anemia Drugs Jan. 1, 2020 Used to treat anemia. Will add PA requirement for all Commercial Plans, and Community and State plans for the following codes: J0885; J0888.
Avastin Oct. 1, 2019 Used to treat certain types of cancer and ophthalmic conditions. Removed PA requirement for non-cancer use from Neighborhood Health Partnership.
Hereditary Angioedema Oct. 1, 2019 Used to treat hereditary angioedema. Removed PA requirement from Neighborhood Health Partnership for the following codes: J0596; J0597; J0598; J1290.
Rituxan® Oct. 1, 2019 Used to treat certain types of cancer, and rheumatoid arthritis. Removed PA requirement for non-cancer use from affiliate plans UnitedHealthcare of the Mid-Atlantic, Inc., UnitedHealthcare of the River Valley and Neighborhood Health Partnership. 
Makena® Oct. 1, 2019 Used to prevent preterm labor. Removed PA requirement from affiliate plans UnitedHealthcare of the Mid-Atlantic, Inc., UnitedHealthcare of the River Valley and Neighborhood Health Partnership.  Codes include: J1726; J1729.
Ophthalmologic Drugs Oct. 1, 2019 Ophthalmologic use. Removed PA requirement from Neighborhood Health Partnership for the following codes: J0178; J2503; J2778.
Erythropoiesis-Stimulating Agents
Procrit® 
Epogen®
Jan. 1, 2020 Used to treat anemia due to myelosuppressive chemotherapy, chronic kidney disease (CKD), and zidovudine therapy for patients with HIV-infection. Notification/prior authorization required for J0885. This requirement only applies to non-end stage renal disease patients.
Esperoct® Jan. 1, 2020 Used to treat hemophilia A for on-demand treatment and control of bleeding episodes, perioperative management of bleeding, and routine prophylaxis to reduce the frequency of bleeding episodes.   Notification/prior authorization required.
Xembify® Jan. 1, 2020 Used to treat Primary Humoral Immunodeficiency (PI) in patients 2 years of age and older. Notification/prior authorization required.For UHC Commercial members, if Xembify is requested in the outpatient hospital setting, this site of care will be reviewed for medical necessity.

Changes to our drug policies

Drug policy changes
Drug Name Effective Date Treatment Uses Summary of Changes
Oncology Medication Clinical Coverage  Oct. 1, 2019 Used to treat oncology conditions as per the National Comprehensive Cancer Network (NCCN) Drugs & Biologics Compendium® (NCCN Compendium®).

Includes preferred product coverage criteria for Avastin® (bevacizumab) and Herceptin® (trastuzumab). Preferred product language was added: 

  • Use of Mvasi (bevacizumab-awwb) prior to the use of Avastin and other bevacizumab biosimilar products. 
  • Use of Kanjinti (trastuzumab-anns) prior to the use of Herceptin and other trastuzumab biosimilar products.
White Blood Cell Colony Stimulating Factors Oct. 1, 2019 Used to treat Neutropenia. Includes preferred product coverage criteria. Preferred product language was added: Use of Zarxio® prior to the use of Granix®, Neupogen® and Nivestym™.
Infliximab (Remicade®, Inflectra®, Renflexis®) Erythropoiesis-Stimulating Agents Oct. 1, 2019 Used to treat Crohn’s disease, ulcerative colitis, rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis and plaque psoriasis. No longer require the use of Remicade prior to coverage for Inflectra. As part of the notification/prior authorization review, we require documentation to support the clinical requirement that members must try both Inflectra and Remicade, experience an adverse reaction, or have a contradiction to Inflectra and Remicade in order to receive coverage approval for Renflexis. 
Erythropoiesis-Stimulating Agents Jan. 1, 2020 Used to treat anemia due to myelosuppressive chemotherapy,chronic kidney disease (CKD) in patients on dialysis and not on dialysis, zidovudine therapy in patients with HIV-infection.  Policy includes preferred product coverage criteria. Retacrit must be used prior to the coverage of Epogen or Procrit.