Specialty medical injectable drug program, requirements and drug policy updates for January

Specialty medical injectable drug program, requirements and drug policy updates for January.


Review the following table to determine changes to our specialty medical injectable drug programs.


SPECIALTY MEDICAL INJECTABLE DRUGS ADDED TO MEDICATION SOURCING FOR OUTPATIENT FACILITY PROVIDERS ONLY

For UnitedHealthcare commercial business

Drug Name Effective Date Therapeutic Class HCPCS Code(s) Specialty Pharmacy
Adzynma (ADAMTS13, recombinant-krhn) 4/1/24 Enzyme Replacement Therapy J3490, J3590, C9399 TBD
Omvoh™ - IV formulation(mirikizumab-mrkz) 4/1/24 Inflammatory Conditions J3490, J3590, C9399 Amber Specialty Pharmacy
Pombiliti™
(cipaglucosidase alfa)
4/1/24 Enzyme Replacement Therapy C9162 Orsini Pharmaceutical Services

Review the UnitedHealthcare Commercial Plan Medication Sourcing List.

For questions, please contact your broker or UnitedHealthcare representative.

UPDATES TO DRUG PROGRAM REQUIREMENTS AND DRUG POLICIES

For UnitedHealthcare commercial business effective April 1, 2024

Drug Name Treatment Uses Summary of Changes
Adzynma
(ADAMTS13, recombinant-krhn)
Used for on demand or prophylactic enzyme replacement therapy in adult and pediatric patients with congenital thrombotic thrombocytopenia purpura. Add prior authorization/notification

Add to Site of Care
Casgevy™
(exagamglogene autotemcel)
Gene-editing therapy for patients with severe sickle cell disease.

Add prior authorization/notification

Will be managed by Optum Transplant and be given inpatient

Lantidra
(donislecel)
Allogeneic pancreatic islet cellular therapy used in conjunction with concomitant immunosuppression for the treatment of adults with Type 1 diabetes who are unable to approach target HbA1c because of current repeated episodes of severe hypoglycemia despite intensive diabetes management and education.

Add prior authorization/notification

Will be managed by Optum Transplant and be given inpatient

Lyfgenia™
(lovotibeglogene autotemcel)
Gene-editing therapy for patients with severe sickle cell disease.

Add prior authorization/notification

Will be managed by Optum Transplant and be given inpatient

Omvoh™ - IV formulation(mirikizumab-mrkz) Used for the treatment of moderately to severely active ulcerative colitis in adults. Add prior authorization/notification

Add to Site of Care
Pombiliti™
(cipaglucosidase alfa)
Used as a long-term enzyme replacement therapy in combination with Opfolda™ (covered under the pharmacy benefit) for the treatment of adults with late-onset Pompe disease who are not improving on their current enzyme replacement therapy. Add prior authorization/notification

Add to Site of Care

Add as non-preferred product – Nexviazyme® or Lumizyme® are preferrred

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.

For questions, please contact your broker or UnitedHealthcare representative.

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