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    v1.0.28
    OpenPayerPolicy UpdatesNeurology/NeurosurgeryAvMed Briumvi prior Auth Policy Update | OpenPayer
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    CurrentAvMedPolicy Pub. 100-2

    Briumvi (ublituximab) prior authorization

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    Requirements and clinical criteria for AvMed medical prior authorization and step-edit requests for Briumvi (ublituximab) for treatment of relapsing forms of multiple sclerosis; applies to providers submitting requests for AvMed members.

    Policy Summary
    PayerAvMed
    PolicyBriumvi (ublituximab) prior authorization
    Policy CodePolicy Pub. 100-2
    Change TypeNo material changes
    Effective Date
    Next Review Date
    Key ActionObtain prior authorization and prescriber signature on the AvMed medical prior authorization/step-edit request form and supply supporting documentation including chart notes or pharmacy claims for prior DMT trials.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    Initial 6 monthsAuthorization length for new starts
    Reauthorization 12 monthsRenewal authorization length
    150 mg then 450 mg

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Initial dosing regimen
    450 mg q6 monthsMaintenance dosing
    J2329Billing code listed

    Coverage Criteria for Briumvi (ublituximab)

    Initial Authorization

    Covered when ALL of the following are met for initial authorization (approval for 6 months):

    Initial Authorization: Prescriber is a Neurologist
    Initial Authorization: Member is 18 years of age or older
    • ONE of: Relapsing-remitting MS (RRMS)
    • ONE of: Active Secondary-progressive MS (SPMS)
    • ONE of: Clinically Isolated Syndrome (CIS)
    • At least ONE of: dimethyl fumarate (Tecfidera)
    • At least ONE of: glatiramer acetate (Glatopa or Copaxone)
    • At least ONE of: fingolimod (Gilenya)
    • At least ONE of: teriflunomide (Aubagio)
    Initial Authorization: Prescriber attests to ALL of the following: quantitative serum immunoglobulins tested prior to initiation; member does NOT have an active hepatitis B virus infection; medication will NOT be given concurrently with live vaccines; member has had at least ONE medically documented clinical relapse within the previous 12 months
    Initial Authorization: Member does NOT have concurrent use of other MS disease modifying agentsall lines must be checked and supported by documentation

    Initial authorization duration: 6 months.

    Reauthorization

    Covered when ALL of the following are met for reauthorization (approval for 12 months):

    Reauthorization: Member continues to demonstrate a positive clinical response to therapy
    Reauthorization: Member has NOT developed any contraindications or other significant adverse effects that may exclude continued use
    Reauthorization: Member does NOT have concurrent use of other MS disease modifying therapiesall lines must be checked and supported by documentation

    Reauthorization duration: 12 months.

    Concurrent use of other disease-modifying therapies for multiple sclerosis is not permitted. For both initial authorization and reauthorization, the prescriber must attest that the member does NOT have concurrent use of other MS disease modifying agents or therapies; requests that document concurrent use will not meet criteria for approval.

    Requests for Briumvi that include concurrent use of other MS disease modifying therapies, or that do not meet the required diagnosis, prior therapy trial(s), and pre-treatment testing/attestations, do not meet the coverage criteria. Specifically, approval requires the confirmed relapsing MS diagnosis, documentation of trial and failure of at least one listed disease-modifying agent, and prescriber attestations including baseline quantitative serum immunoglobulins, exclusion of active hepatitis B infection, and avoidance of live vaccines; absence of these will render the request not approvable.

    Coding and Billing

    Listed drug HCPCSHCPCS
    J2329ublituximab
    Billable unitsmixed
    150 mg/6 mL vial1 vial (150 mg/6 mL) = 150 billable units
    Coding — Billable unit definition
    Billable unit definition1 vial (150 mg/6 mL) = 150 billable units
    Vial size150 mg / 6 mL per vial
    Billing units per mg150 billable units correspond to the 150 mg vial

    Provider Actions, Requirements, and Risks

    Prior Authorization

    Prior authorization and prescriber signature required

    Prior authorization is required for Briumvi (ublituximab) (J2329) using the AvMed medical prior authorization/step-edit request form; the prescribing physician must sign and clearly print name (preprinted stamps not valid) on the request.

    Step Therapy

    Step therapy — prior therapy trial required

    Member must have tried and failed at least one listed disease‑modifying therapy, verified by chart notes or pharmacy paid claims (examples: dimethyl fumarate, glatiramer acetate, fingolimod, teriflunomide).

    • Verification accepted: chart notes or pharmacy paid claims
    • Agents listed on form must be checked as tried

    Dosing and Definitions

    Definitions — Initial and maintenance dosing
    Initial dosing regimenInitial dose: 150 mg IV, followed 2 weeks later by a 450 mg IV infusion
    Second dose timingSecond (450 mg) infusion given 2 weeks after the 150 mg initial infusion
    Maintenance dosingSubsequent doses: single 450 mg IV infusion every 6 months
    Administration routeIntravenous infusion for all doses

    Background

    Briumvi (ublituximab) is an intravenous monoclonal antibody indicated for relapsing forms of multiple sclerosis. The prior authorization form specifies the initial dosing regimen as a 150 mg IV infusion followed two weeks later by a 450 mg IV infusion, with subsequent maintenance dosing of a single 450 mg IV infusion every 6 months. Baseline requirements include quantitative serum immunoglobulin testing and exclusion of active hepatitis B infection prior to initiation; these attestations must be documented on the request.

    Policy Summary
    PayerAvMed
    PolicyBriumvi (ublituximab) prior authorization
    Policy CodePolicy Pub. 100-2
    Change TypeNo material changes
    Effective Date
    Next Review Date
    Key ActionObtain prior authorization and prescriber signature on the AvMed medical prior authorization/step-edit request form and supply supporting documentation including chart notes or pharmacy claims for prior DMT trials.
    SourceLink
    On This Page
    Coverage Criteria for Briumvi (ublituximab)Coding and BillingProvider Actions, Requirements, and RisksDosing and DefinitionsBackground
    Documentation Required

    Submit supporting documentation for each checked criterion

    Provide supporting documentation for each checked clinical criterion on the form, including lab results, diagnostics, and chart notes; prior therapies will be verified by chart notes or pharmacy paid claims.

    • Include quantitative serum immunoglobulin test results prior to initiation (per attestation)
    • Include documentation of at least one medically documented clinical relapse in prior 12 months
    Denial Risk

    Incomplete or illegible documentation may delay or deny authorization

    Authorization can be delayed or denied if the request form information is incomplete, incorrect, or illegible; ensure all required fields and supporting documentation are complete and readable.

    • Prescriber signature must be handwritten and clearly printed (preprinted stamps not valid)
    • Incomplete or illegible information may delay or result in denial