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

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

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.

ref

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.

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

SourceLink

On This Page

OpenPayer

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

Coverage Summary

Initial Therapy Criteria

Continuation / Reauthorization Criteria

Provider Actions & Administrative Requirements

Applicable Codes

Clinical Evidence & References

Background & Definitions

Revision History