Colorado Rocky Mountain HP Alunbrig Prior Auth | OpenPayer

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Colorado Rocky Mountain HP Alunbrig Prior Auth | OpenPayer

Provider Authorization & Documentation Actions

Prior Authorization

Prior authorization required — NSCLC initial

Prior authorization is required for initial Alunbrig (brigatinib) use in ALK-positive NSCLC and will be approved when all criteria are met: diagnosis of non-small cell lung cancer (NSCLC); disease is metastatic, recurrent, or advanced; and tumor is ALK-positive. Authorization will be issued for 12 months.

Diagnosis: non-small cell lung cancer (NSCLC)
Disease status: metastatic, recurrent, or advanced
Tumor: anaplastic lymphoma kinase (ALK)-positive
Authorization duration: 12 months

Prior Authorization

Prior authorization required — IMT initial

Prior authorization is required for initial Alunbrig use in inflammatory myofibroblastic tumor (IMT) and will be approved when both criteria are met: diagnosis of IMT and presence of an ALK translocation. Authorization will be issued for 12 months.

Diagnosis: inflammatory myofibroblastic tumor (IMT)
Molecular: documented ALK translocation
Authorization duration: 12 months

Prior Authorization

Prior authorization required — Histiocytic neoplasms (ECD) initial

Prior authorization is required for initial Alunbrig use in symptomatic Erdheim‑Chester Disease (ECD) and will be approved when all criteria are met: diagnosis of symptomatic ECD, use as targeted therapy for an ALK‑fusion, and disease that is relapsed or refractory. Authorization will be issued for 12 months.

Diagnosis: symptomatic Erdheim‑Chester Disease (ECD)
Indication: targeted therapy for ALK‑fusion
Disease status: relapsed or refractory
Authorization duration: 12 months

Prior Authorization

Prior authorization required — Anaplastic large cell lymphoma initial

Prior authorization is required for initial Alunbrig use in anaplastic large cell lymphoma and will be approved when all criteria are met: diagnosis of anaplastic large cell lymphoma, tumor is ALK‑positive, disease is relapsed or refractory, and use is for palliative intent or second‑line/subsequent therapy. Authorization will be issued for 12 months.

Diagnosis: anaplastic large cell lymphoma
Tumor: ALK‑positive
Disease status: relapsed or refractory
Intent: palliative or second‑line/subsequent therapy
Authorization duration: 12 months

Prior Authorization

Prior authorization required — CNS metastases initial

Prior authorization is required for initial Alunbrig use for metastatic brain cancer from NSCLC and will be approved when both criteria are met: diagnosis of metastatic brain cancer from NSCLC and tumor is ALK‑positive. Authorization will be issued for 12 months.

Diagnosis: metastatic brain cancer from NSCLC
Tumor: ALK‑positive
Authorization duration: 12 months

Step Therapy

Automated approval and re‑approval may be used

UnitedHealthcare may use automated approval and re‑approval processes based on prior claim or medication history and claim logic; use of these automated processes varies by program and therapeutic class.

Automated approvals/re‑approvals can be based solely on previous claims/medication history and diagnosis codes (ICD‑10) or claim logic
Use of automated processes varies by program and therapeutic class

Documentation Required

Coverage decisions informed by claims, diagnosis codes, and compendia

Coverage decisions may be based on prior claim/medication history, diagnosis codes (ICD‑10), and claim logic; references informing decisions include the Alunbrig package insert and the NCCN Drugs and Biologics Compendium.

Data sources: prior claim/medication history, diagnosis codes (ICD‑10), and claim logic
Referenced materials: Alunbrig package insert; NCCN Drugs and Biologics Compendium

Denial Risk

External factors may affect authorization and risk denial

Requests may be affected by state mandates, the member’s benefit plan, and other utilization management programs; failure to meet payer criteria or applicable mandates may result in denial. For members under 19 years, prescriptions automatically process without coverage review.

State mandates or member‑specific benefit coverage may supersede or modify coverage criteria
Noncompliance with payer criteria or mandates can trigger denial
Members under age 19: prescription auto‑processes without coverage review