Jul 26, 2023
Please review the following tables to determine changes to UnitedHealthcare's specialty medical injectable drug programs.
| DRUG NAME | TREATMENT USES |
|---|---|
| Elevidys (delandistrogene moxeparvovec-rokl) |
Gene therapy used for the treatment of Duchenne muscular dystrophy in ambulatory pediatric patients aged 4 through 5. |
| Roctavian™ (valoctocogene roxaparvovec-rvox) |
Gene therapy for the treatment of adults with hemophilia A – an inherited genetic disorder caused by insufficient levels of the clotting protein, factor VIII. |
| Vyjuvek™ (beremagene geperpavec-svdt) |
Used for the treatment of wounds in patients 6 months of age and older with dystrophic epidermolysis bullosa. |
| Vyvgart® Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) |
Used for the treatment of generalized myasthenia gravis (gMG) in adult patients who are anti-acetylcholine receptor (AChR) antibody positive. |
| THERAPEUTIC CLASS | EXCLUDED MEDICATIONS | OTHER OPTIONS |
|---|---|---|
| VEGF | Beovu®, Byooviz™ (Lucentis biosimilar) | Avastin®, Eylea®, Lucentis®, Cimerli™ (Lucentis biosimilar), Vabysmo® |
| Immune Globulin | Cuvitru™ | Bivigam®, Carimune®, Flebogamma®, Gammagard®, Gammaked™, Gammaplex®, Gamunex-C®, Hizentra®, Hyqvia™, Octagam®, Privigen®, Xembify® |
| DRUG NAME | THERAPEUTIC CLASS | HCPC CODE(S) | SPECIALTY PHARMACY |
|---|---|---|---|
| Beovu® | VEGF | Q5124 | To be determined |
| Briumvi™ | Multiple Sclerosis | J2329 | To be determined |
| Byooviz™ | VEGF | J0179 | To be determined |
| Elevidys* | Gene Therapy | J3490, J3590, C9399 | To be determined |
| Lamzede® | Enzyme Replacement Therapy | J3490, J3590, C9399 | Eversana |
| Qalsody™ | CNS Agents | J3490, J3590, C9399 | Optum Frontier Pharmacy |
| Syfovre™ | Complement Inhibitors — Opthalmologic Use | C9151 | To be determined |
| Vyjuvek™* | Gene Therapy | J3490, J3590, C9399 | To be determined |
| DRUG NAME | TREATMENT USES | SUMMARY OF CHANGES |
|---|---|---|
| Altuviiio™ (antihemophilic factor (recombinant), Fc-VWF-XTEN fusion protein-ehtl) |
Used for routine prophylaxis and on-demand treatment to control bleeding episodes, as well as perioperative management (surgery) for adults and children with hemophilia A. | Add notification/prior authorization |
| Briumvi™ (ublituximab-xiiy) |
Used for the treatment of adults with relapsing forms of multiple sclerosis (MS). | Add notification/prior authorization |
| Elevidys (delandistrogene moxeparvovec-rokl) |
Gene therapy used for the treatment of Duchenne muscular dystrophy in ambulatory pediatric patients age 4 through 5. | Add notification/prior authorization |
| Lamzede® (velmanase alfa-tycv) |
Used for the treatment of non-central nervous system manifestations of alpha-mannosidosis in adult and pediatric patients. | Add notification/prior authorization in outpatient place of service and Site of Care |
| Qalsody™ (tofersen) |
Used for the treatment of amyotrophic lateral sclerosis (ALS) in adults who have a mutation in the superoxide dismutase 1 (SOD1) gene. | Add notification/prior authorization |
| Syfovre™ (pegcetacoplan injection) |
Used for the treatment of geographic atrophy (GA) secondary to age-related macular degeneration (AMD). | Add notification/prior authorization |
| Vyjuvek™ (beremagene geperpavec-svdt) |
Used for the treatment of dystrophic epidermolysis bullosa (DEB) in pediatric and adult patients. | Add notification/prior authorization and Site of Care |
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.
Contact your Amwins Connect Regional Sales Manager for more information.
