CurrentMass General Brigham Health PlanPolicy N/A

Briumvi (ublituximab-xiiy) — coverage and prior authorization

Defines prior authorization, coverage criteria, continuation requirements, and limits for Briumvi for treatment of relapsing forms of multiple sclerosis for Mass General Brigham Health Plan members.

Policy Summary

PayerMass General Brigham Health Plan

PolicyBriumvi (ublituximab-xiiy) — coverage and prior authorization

Policy CodePolicy N/A

Change TypeMaterial addition: prior authorization added for Briumvi on pharmacy and medical benefits

Effective DateMay 12, 2025

Next Review DateN/A

Key ActionSubmit a prior authorization request with neurologist documentation and requested dosing per policy (150 mg initiation then 450 mg maintenance).

SourceLink

POLICY UPDATE CHANGES

Briumvi (ublituximab-xiiy) was added as a drug requiring prior authorization through pharmacy and medical benefits and has an individual policy.

Policy updated to indicate all agents except Briumvi and Ocrevus were pharmacy benefit only and removed from medical benefit listing.

12 monthsInitial and reauthorization length

450 mg IVMaintenance dosing interval

150 mg then 450 mgInitiation dosing schedule

Prior Auth

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Coverage Criteria for Briumvi (ublituximab-xiiy)

Initial Therapy — Authorization may be granted when ALL of the following are met.

Authorization may be granted when ALL of the following are met:

Briumvi initial authorization criteria: Member has a diagnosis of one of the relapsing forms of multiple sclerosis (clinically isolated syndrome, relapsing‑remitting MS, or active secondary‑progressive MS)

Applied to members new to plan and others when not currently receiving medication via samples or manufacturer patient assistance programs

Prescriber requirement: Prescriber is a neurologist or consult notes from a neurology office are provided

Dosing requirement: Requested dose is 450 mg IV every 24 weeks; if initiating therapy, first dose given as 150 mg IV on day 1 followed by 450 mg IV two weeks later450 mg IV every 24 weeks

Continuation of Therapy — Reauthorization requirements by indication.

Reauthorization requirements by indication:

RRMS reauthorization: Physician attestation of continuation of therapy and positive response to therapy required

12-month reauthorization interval applies

SPMS reauthorization: Physician attestation of active disease, continuation of therapy and positive response to therapy required

12-month reauthorization interval applies

CIS reauthorization: Reauthorization will be evaluated on a case-by-case basis

12-month reauthorization interval applies

Requests for members who do not meet the clinical criteria and who are not currently receiving the medication are not eligible for case‑by‑case continuation review. This exclusion applies when the member is not actively receiving the requested drug and the drug was not obtained as samples or through a manufacturer patient assistance program. Such requests should be denied unless the member meets the documented clinical criteria and other authorization requirements.

This policy requires use of the specified initiation and maintenance dosing. The approved initiation schedule is 150 mg IV on day 1 followed by 450 mg IV two weeks later, and the approved maintenance dose is 450 mg IV every 24 weeks. Use of doses or schedules other than these specified regimens is not described as covered by this policy and should be considered not medically necessary.

Coding and Dosing Details

Pharmacy benefit listing referenceNDC

NDC	See MassHealth Drug List for Briumvi pharmacy benefit NDC and coverage

Dose interval

Maintenance dosing interval450 mg IV every 24 weeks

Initiation dosing schedule150 mg IV on day 1 then 450 mg IV two weeks later

Route of administrationIntravenous (IV) infusion

Provider Actions and Authorization Rules

Prior Authorization

Prior Authorization Required

Prior authorization is required for Briumvi; requests are reviewed case-by-case for members new to the plan who are currently receiving the medication.

Applies to members new to the plan who are currently receiving Briumvi
Excludes product obtained as samples or via manufacturer's patient assistance programs

Step Therapy

Step Option with Ocrevus

Briumvi was added as a step-through option for Ocrevus under the pharmacy benefit; verify step-therapy requirements and pharmacy benefit lists for details.

Check the pharmacy benefit drug list for step therapy sequencing and any required trial of Ocrevus prior to Briumvi under the pharmacy benefit

Background

Briumvi (ublituximab‑xiiy) is indicated for treatment of relapsing forms of multiple sclerosis, which include clinically isolated syndrome, relapsing‑remitting multiple sclerosis, and active secondary‑progressive multiple sclerosis. Authorization under this policy aligns with standard neurologic prescribing and the dosing regimen described for initiation and maintenance therapy.

Definitions

Relapsing forms of multiple sclerosis

Included conditionsClinically isolated syndrome, relapsing‑remitting MS, and active secondary‑progressive MS

Patient populationAdults with relapsing forms of multiple sclerosis

Policy relevanceThese diagnoses constitute the covered indications for Briumvi under this policy