ModifiedColorado Rocky Mountain Health PlansPolicy 2026 P 1514-1

Wayrilz™ (rilzabrutinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plansopen_in_new

UnitedHealthcare prior authorization/notification policy for Wayrilz (rilzabrutinib) for treatment of adult patients with persistent or chronic immune thrombocytopenia (ITP); defines initial and reauthorization clinical criteria and authorization duration.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyWayrilz™ (rilzabrutinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plansopen_in_new

Policy CodePolicy 2026 P 1514-1

Change TypeNew program (P&T approval 2/2026)

Effective DateMay 1, 2026

Next Review Date

Key ActionPrior authorization/notification is required for Wayrilz; initial approval requires documentation of diagnosis of persistent or chronic ITP and prior insufficient response to previous treatments; reauthorization requires documentation of positive clinical response.

SourceLink

POLICY UPDATE CHANGES

New program for Prior Authorization/Notification for Wayrilz (rilzabrutinib) created with P&T approval 2/2026 and effective date 5/1/2026.

1Covered Indications (ITP)

12 moAuthorization Duration (reauthorization)

2026-02P&T Approval

Coverage Summary

UnitedHealthcare prior authorization/notification policy for Wayrilz (rilzabrutinib) for treatment of adult patients with persistent or chronic immune thrombocytopenia (ITP); covered_with_criteria. Wayrilz (rilzabrutinib) is indicated for treatment of adult patients with persistent or chronic ITP who have had an insufficient response to a previous treatment.

Key Policy Information

Policy Number2026 P 1514-1

Effective Date2026-05-01

Last Review2026-02-01

P&T Approval2026-02

Authorization Duration12 months

Initial Therapy Criteria

Initial Authorization

Wayrilz will be approved based on both of the following criteria:

Diagnosis of persistent or chronic immune thrombocytopenia (ITP)
Patient has had an insufficient response to a previous treatment (e.g., corticosteroids, immunoglobulins, thrombopoietin receptor agonists, splenectomy)
Definition: 'Insufficient response' not explicitly defined in policy; example prior treatments include corticosteroids, immunoglobulins, thrombopoietin receptor agonists, splenectomy.

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Continuation / Reauthorization Criteria

Reauthorization (Continuation)

Wayrilz will be approved based on the following criterion:

Documentation of positive clinical response to Wayrilz therapy

Authorization will be issued for 12 months for reauthorization.

Provider Actions & Administrative Requirements

Prior Authorization

Prior authorization required

Prior authorization/notification is required for Wayrilz; initial approval requires documentation of diagnosis of persistent or chronic ITP and prior insufficient response to previous treatments; reauthorization requires documentation of positive clinical response.

Documentation Required

Acceptable evidence for automated approval

UnitedHealthcare may approve initial and re-authorization based solely on previous claim/medication history, diagnosis codes (ICD-10) and/or claim logic; use of automated processes varies by program.

Step Therapy

Step therapy / supply limits may apply

Supply limits, Medical Necessity, and/or Step Therapy may be in place and applicable to Wayrilz.

Billing Rule

Authorization duration

Authorization will be issued for 12 months for reauthorization.

Background & Definitions

Wayrilz (rilzabrutinib) is a kinase inhibitor indicated for treatment of adult patients with persistent or chronic immune thrombocytopenia (ITP) who have had an insufficient response to a previous treatment.

Insufficient response: Not explicitly defined in policy; example prior treatments include corticosteroids, immunoglobulins, thrombopoietin receptor agonists, splenectomy.

Revision History

2026-02-01added

P&T approval for new Prior Authorization/Notification program for Wayrilz (rilzabrutinib) documented (Change Control 2/2026).

2026-05-01addedLatest