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Review at Launch Medication List UnitedHealthcare® Community Plan Medical Benefit Drug List Review at Launch Medication List Last Modified Date: August 16, 2021 Table of Contents Page Instructions for Use ....................................................................... 1 Applicable Medications ................................................................. 1 List History/Revision Information ................................................. 1 Instructions for Use This Review at Launch Medication List provides the names of medications that are subject to the Medical Benefit Drug Policy titled Review at Launch for New to Market Medications and therefore, require review prior to administration. When deciding coverage, the federal, state or contractual requirements for benefit plan coverage must be referenced. The terms of the federal, state or contractual requirements for benefit plan coverage may differ greatly from the standard benefit plan upon which the aforementioned Review at Launch Drug Policy is based. In the event of a conflict, the federal, state or contractual requirements for benefit plan coverage supersede said drug policy. All reviewers must first identify member eligibility, any federal or state regulatory requirements, and the contractual requirements for benefit plan coverage prior to use. Other Policies and Coverage Determination Guidelines may apply. UnitedHealthcare reserves the right, in its sole discretion, to modify its Policies and Guidelines as necessary. Applicable Medications This medication list includes new medications that are: Food and Drug Administration (FDA) approved; Healthcare provider administered; and Reimbursable on a member’s medical benefit Brand Name (Generic Name) Date the Drug was Added to the Review at Launch Medication List Cabenuva™ (cabotegravir/rilpivirine) 02/01/2021 Evkeeza™ (evinacumab-dgnb) 02/17/2021 Aduhelm™ (aducanumab-avwa) 06/14/2021 Ryplazim® (plasminogen, human-tvmh) 06/14/2021 Saphnelo™ (anifrolumab-fnia) 08/06/2021 Nexviazyme™ (avalglucosidase alfa-ngpt) 08/16/2021 List History/Revision Information Date Summary of Changes ™ 08/16/2021 Added Nexviazyme (avalglucosidase alfa-ngpt) ™ 08/06/2021 Added Saphnelo (anifrolumab-fnia) ™ ™ 07/01/2021 Removed Oxlumo (lumasiran) and Amondys 45 (casimersen) Review at Launch Medication List Page 1 of 3 UnitedHealthcare Community Plan Medical Benefit Drug Policy Effective 08/16/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. Date Summary of Changes 06/14/2021 Added Aduhelm™ (aducanumab-avwa) and Ryplazim® (plasminogen, human-tvmh) Removed Empaveli™ (pegcetacoplan) 05/20/2021 Added Empaveli™ (pegcetacoplan) 04/07/2021 Template Update Removed Related Policies section 03/01/2021 Added Amondys 45™ (casimersen) 02/17/2021 Added Evkeeza™ (evinacumab-dgnb) 02/01/2021 Added Cabenuva™ (cabotegravir/rilpivirine) 01/01/2021 Removed Scenesse® (afamelanotide), Uplizna™ (inebilizumab-cdon), and Viltepso™ (viltolarsen); prior authorization requirements effective Jan. 1, 2021 12/07/2020 Added Oxlumo™ (lumasiran) 10/01/2020 Removed Monoferric™ (ferric derisonmaltose), Tepezza™ (teprotumumab-trbw), and Vyepti™ (eptinezumab-jjmr); prior authorization requirements effective Oct. 1, 2020 09/01/2020 Reformatted list; transferred content to new template 08/18/2020 Added Viltepso™ (viltolarsen) 07/01/2020 Removed Adakveo® (crizanlizumab-tmca), Avsola™ (infliximab-axxq), Givlaari™ (givosiran), and Vyondys 53™ (golodirsen); prior authorization requirements effective Jul. 1, 2020 ™ ® 06/19/2020 Added Uplizna (inebilizumab-cdon) and Scenesse (afamelanotide) ™ 04/01/2020 Added Vyepti (eptinezumab-jjmr) Removed: ® o Reblozyl (luspatercept-aamt); prior authorization requirements effective Apr. 1, 2020 ® o Zolgensma (onasemnogene abeparvovec-xioi); prior authorization requirements effective Oct. 1, 2019 03/01/2020 Added Avsola™ (infliximab-axxq) 02/01/2020 Added Monoferric™ (ferric derisonmaltose) and Tepezza™ (teprotumumab-trbw) 01/22/2020 Removed Cutaquig® [Immune Globulin Subcutaneous (Human) – hipp] and Xembify® [Immune Globulin Subcutaneous (Human) – klhw] [prior authorization requirements apply Jan. 1, 2020; refer to the Medical Benefit Drug Policy titled Immune Globulin (IVIG and SCIG) for coverage guidelines] 12/16/2019 Added Givlaari™ (givosiran) and Vyondys 53™ (golodirsen) 11/25/2019 Added Adakveo® (crizanlizumab-tmca) and Reblozyl® (luspatercept-aamt) 10/01/2019 Removed Spravato™ (esketamine) and Evenity™ (romosozumab-aqqg); prior authorization requirements effective Oct. 1, 2019 08/01/2019 Added Xembify® [Immune Globulin Subcutaneous (Human) – klhw] 07/01/2019 Removed Ultomiris™ (ravulizumab-cwvz); prior authorization requirements effective Jul. 1, 2019 06/10/2019 Added Cutaquig® [Immune Globulin Subcutaneous (Human) – hipp] 05/29/2019 Added Zolgensma® (onasemnogene abeparvovec-xioi) 04/22/2019 Added Evenity™ (romosozumab-aqqg) 04/01/2019 Removed Gamifant® (emapalumab-lzsg); prior authorization requirements effective Apr. 1, 2019 03/22/2019 Added Spravato™ (esketamine) 01/02/2019 Added Ultomiris™ (ravulizumab-cwvz) Removed Ilumya™ (tildrakizumab-asmn) and Onpattro™ (patisiran); prior authorization requirements effective Jan. 1, 2019 ® 11/20/2018 Added Gamifant (emapalumab-lzsg) ® 10/01/2018 Removed Crysvita (burosumab-twza); prior authorization requirements effective Oct. 1, 2018 ™ 08/15/2018 Added Onpattro (patisiran) Review at Launch Medication List Page 2 of 3 UnitedHealthcare Community Plan Medical Benefit Drug Policy Effective 08/16/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. Date Summary of Changes 07/01/2018 Added Ilumya™ (tildrakizumab-asmn) Removed Sublocade™ (buprenorphine-extended release) and Trogarzo™ (ibalizumab-uiyk); prior authorization requirements effective Jul. 1, 2018 04/23/2018 Added Crysvita® (burosumab-twza) 04/01/2018 Removed Luxturna™ (voretigene neparvovec-rzyl); prior authorization requirements effective Apr. 1, 2018 ™ 03/23/2018 Added Trogarzo (ibalizumab-uiyk) ™ 01/22/2018 Added Sublocade (buprenorphine-extended release) ™ 01/01/2018 New list; includes Luxturna (voretigene neparvovec-rzyl) Review at Launch Medication List Page 3 of 3 UnitedHealthcare Community Plan Medical Benefit Drug Policy Effective 08/16/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. .
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