CurrentColorado Rocky Mountain Health Plans | UnitedHealthcare Pharmacy Clinical Pharmacy ProgramsPolicy N/A

Modeyso® (dordaviprone) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Prior authorization/notification policy for Modeyso (dordaviprone) for UnitedHealthcare commercial plans (program effective 2026-01-01; P&T approval 10/2025). Covers adults and pediatric patients ≥1 year with diffuse midline glioma harboring H3 K27M mutation after prior therapy; special auto-approval for members under 19.

Policy Summary

PayerColorado Rocky Mountain Health Plans | UnitedHealthcare Pharmacy Clinical Pharmacy Programs

PolicyModeyso® (dordaviprone) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Policy CodePolicy N/A

Change TypeNew prior authorization program

Effective DateJan 1, 2026

Next Review Date

Key ActionPrescriptions for Modeyso require prior authorization/notification; members under age 19 will automatically process without coverage review and authorizations are issued for 12 months.

SourceLink

POLICY UPDATE CHANGES

New prior authorization program created for Modeyso (dordaviprone) with P&T approval 10/2025 and effective date 1/1/2026.

12 monthsAuthorization duration

Age <19Pediatric auto-approval

H3 K27MMolecular biomarker requirement

Coverage Summary

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This policy is a Prior Authorization/Notification program for Modeyso (dordaviprone) for UnitedHealthcare commercial plans with P&T approval 10/2025 and program effective date 1/1/2026. It covers adult and pediatric patients aged 1 year and older with diffuse midline glioma harboring an H3 K27M mutation following prior therapy. Members under the age of 19 years will have prescriptions automatically processed without coverage review. Coverage stance: Covered with criteria.

Key coverage facts

Authorization duration12 months

Pediatric auto-approvalAge <19 auto-approve (prescription processes without coverage review)

Molecular biomarker requirementH3 K27M mutation required

Effective date2026-01-01

P&T approval10/2025

Initial Therapy Criteria

Initial Authorization

Modeyso will be approved based on all of the following:

ALL of the following

Diagnosis (one of)
- Diffuse midline glioma
- High-grade glioma
Disease is positive for an H3 K27M mutation
Disease status (one of)
- Recurrent
- Progressive

Patients less than 19 years of age

Modeyso will be approved based on the following criterion:

ALL of the following

Patient is less than 19 years of age

Provider Actions & Requirements

Prior Authorization

Prior authorization required for Modeyso

Prescriptions for Modeyso require prior authorization/notification per the program. Members under age 19 will automatically process without a coverage review. Authorization, when issued, is for 12 months.

Documentation Required

Clinical documentation required

For initial authorization, document the diagnosis (diffuse midline glioma or high-grade glioma), evidence of H3 K27M mutation positivity, and that the disease is recurrent or progressive. For reauthorization, document that the patient does not show evidence of progressive disease while on Modeyso therapy.

Billing Rule

Supply limits and automated approval

Supply limits may be in place. UnitedHealthcare may approve initial and reauthorization requests based solely on prior claim/medication history, diagnosis codes (ICD-10) and/or claim logic using automated approval processes.

Background & Definitions

Modeyso (dordaviprone) is a protease activator indicated for treatment of adult and pediatric patients 1 year of age and older with diffuse midline glioma harboring an H3 K27M mutation and with progressive disease following prior therapy. The drug is recognized in the NCCN Drugs and Biologics Compendium (Category 1, 2A, or 2B). Some state mandates may apply and can supersede the policy language.

Term	Definition
Modeyso	Brand name for dordaviprone
H3 K27M mutation	A specific histone H3 mutation associated with diffuse midline glioma