Requirement updates for specialty medical injectable drugs
- All States
- Fully Insured and Self-Funded
- Specialty Benefits
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.
|Drug Name||Treatment Uses|
|Adakveo (crizanlizumab-tmca)||To reduce the frequency of vaso-occlusive crises in adults and pediatric patients age 16 and older with sickle cell disease.|
|P;p;' GivlaariTM (givosiran)||For the treatment of adult patients with acute hepatic porphyria.|
|Reblozyl (luspatercept-aamt)||For the treatment of anemia in adult patients with beta-thalassemia who require regular blood transfusions.|
|Vyondys 53 (golodirsen)||For the treatment of Duchenne muscular dystrophy (DMD) that is amenable to exon 53 skipping.|
For more information and a complete list, download the UnitedHealthcare Commercial Plan Review at Launch medication list.
Drugs requiring notification/prior authorization and updated policies
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.
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.
|Drug Name||Effective Date||Treatment Uses||Summary Changes|
Erythropiesis - Stimulating Agents
|Jan. 1, 2020||Used to treat anemia due to various reasons such as chemotherapy and chronic kidney disease.||
Policy includes coverage criteria. Retacrit®, a biosimilar, must be used prior to the coverage of Epogen® or Procrit®.
Retacrit does not require prior authorization.
|Intravenous Iron Replacement Therapy- (Feraheme® and Injectafer®)||April 1, 2020||Injectafer and Feraheme are indicated for the treatment of iron deficiency anemia.||Require notification/prior authorization with a step therapy through lower cost alternative IV iron products.|
|Retuximab - (Rituxan® , RuxienceTM, and Truima®)||April 1, 2020||In addition to treating certain types of cancer, rituximab is used for treating several non-cancer conditions, including rheumatoid arthritis.||
In addition to cancer uses, require notification/prior authorization for non-cancer related conditions.
Feb. 1, 2020 – Adding coverage for multiple sclerosis.
April 1, 2020 – For UnitedHealthcare commercial plans, Rituxan and its biosimilar, Ruxience, are preferred products. Truxima is non-preferred.
|Reblozyl® (Luspatercept- aamt)||July 1, 2020||Reblozyl is for the treatment of anemia in adult patients with beta-thalassemia who require regular blood transfusions.||Require notification/prior authorization.|