UnitedHealthcare Oxford Policy Update Bulletin: March 2021 In This Issue Clinical Policy Updates Page New • Sacroiliac Joint Injections – Effective May 1, 2021 ................................................................................................................................................................................................ 5 Updated • Electric Tumor Treatment Field Therapy – Effective Mar. 1, 2021 ........................................................................................................................................................................ 5 • Gender Dysphoria Treatment – Effective Mar. 1, 2021 .......................................................................................................................................................................................... 5 • Negative Pressure Wound Therapy – Effective Mar. 1, 2021 ................................................................................................................................................................................ 5 Revised • Benlysta® (Belimumab) – Effective Apr. 1, 2021 ..................................................................................................................................................................................................... 6 • Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair – Effective Apr. 1, 2021 ............................................................................................................................................. 9 • Cardiology Procedures Requiring Prior Authorization for eviCore healthcare Arrangement – Effective Jun. 1, 2021 ................................................................................... 10 • Complement Inhibitors (Soliris® & Ultomiris®) – Effective Apr. 1, 2021 ............................................................................................................................................................... 12 • Cosmetic and Reconstructive Procedures – Effective May 1, 2021 ................................................................................................................................................................... 13 • Deep Brain and Cortical Stimulation – Effective May 1, 2021 ............................................................................................................................................................................. 15 • Drug Coverage Criteria – New and Therapeutic Equivalent Medications – Effective Apr. 1, 2021 .................................................................................................................. 16 • Drug Coverage Guidelines – Effective Apr. 1, 2021 ............................................................................................................................................................................................. 16 o Adderall (Amphetamine/ Dextroamphetamin) (Brand Only) ........................................................................................................................................................................ 16 o Adderall XR Amphetamine/ Dextroamphetamin [Extended Release]) ....................................................................................................................................................... 16 o Adhansia XR (Methylphenidate Hydrochloride) ............................................................................................................................................................................................ 16 o Adzenys XR-ODT (Amphetamine Extended-Release) ................................................................................................................................................................................... 17 o Amphetamine/Dextro-Amphetamine Extended-Release (Generic Adderall XR) ........................................................................................................................................ 17 o Apligraf ............................................................................................................................................................................................................................................................. 17 o Aptensio XR ..................................................................................................................................................................................................................................................... 17 o Brukinsa (Zanubrutini)..................................................................................................................................................................................................................................... 17 o Compounds and Bulk Powders: Various Drugs ............................................................................................................................................................................................ 17 o Concerta (Methylphenidate) ........................................................................................................................................................................................................................... 17 Page 1 of 70 UnitedHealthcare Oxford Policy Update Bulletin: March 2021 In This Issue o Cotempla XR-ODT (Methylphenidate) ........................................................................................................................................................................................................... 17 o Cystadrops (Cysteamine) ................................................................................................................................................................................................................................ 17 o Daurismo (Glasdegib) ..................................................................................................................................................................................................................................... 17 o Daytrana (Methylphenidate) ........................................................................................................................................................................................................................... 18 o Desoxyn (Meth-Amphetamine) ....................................................................................................................................................................................................................... 18 o Dexedrine (Dextro-Amphetamine) .................................................................................................................................................................................................................. 18 o Dexmethylphenidate Extended-Release Capsule (Generic Focalin XR) ..................................................................................................................................................... 18 o Dimethyl Fumarate (Generic Tecfidera) ......................................................................................................................................................................................................... 18 o Dojolvi (Triheptanoin) ...................................................................................................................................................................................................................................... 18 o Dyanavel XR (Amphetamine Extended Release) .......................................................................................................................................................................................... 18 o Enspryng .......................................................................................................................................................................................................................................................... 18 o Evekeo (Amphetamine Sulfate) ...................................................................................................................................................................................................................... 18 o Evekeo ODT (Amphetamine Sulfate) ............................................................................................................................................................................................................. 18 o Focalin (Dexmethylphenidate Hcl) ................................................................................................................................................................................................................. 18 o Focalin XR (Dexmethylphenidate Hcl [Extended Release]) ......................................................................................................................................................................... 19 o Forteo (Teriparatide) ....................................................................................................................................................................................................................................... 19 o Jornay PM (Methylphenidate Hydrochloride) ...............................................................................................................................................................................................