CurrentMass General Brigham Health PlanPolicy N/A

Briumvi (ublituximab) prior authorization policy

Defines prior authorization, coverage criteria, continuation, limitations, specialty pharmacy requirement, and contact information for Briumvi (ublituximab) under Mass General Brigham Health Plan / MassHealth UPPL for commercial/exchange plans.

Policy Summary

PayerMass General Brigham Health Plan

PolicyBriumvi (ublituximab) prior authorization policy

Policy CodePolicy N/A

Change TypeAdded

Effective DateJul 1, 2023

Next Review Date

Key ActionPrior authorization is required for Briumvi; specialty designation requires dispensing at a contracted specialty pharmacy. Contact phone and fax provided for authorization requests.

SourceLink

POLICY UPDATE CHANGES

Policy created and reviewed for May P&T; effective 7/1/23.

12 monthsInitial and reauthorization approval duration

Covered w/ criteriaCoverage stance

Coverage Summary

Briumvi (ublituximab) is indicated for treatment of relapsing forms of multiple sclerosis in adults, including clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease. coverage_stance: covered_with_criteria. scope_summary: Defines prior authorization, coverage criteria, continuation, limitations, specialty pharmacy requirement, and contact information for Briumvi (ublituximab) under Mass General Brigham Health Plan / MassHealth UPPL for commercial/exchange plans.

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Initial Therapy Criteria

Initial Authorization

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

ALL of the following

Member has a relapsing form of multiple sclerosis (including relapsing-remitting disease and active secondary progressive disease)
ONE of
- Clinically isolated syndrome of multiple sclerosis
Medication is prescribed by or in consultation with a neurologist.
Member will not use Briumvi concomitantly with other disease modifying multiple sclerosis agents.
Ampyra and Nuedexta are not considered disease modifying agents per policy note.
Authorization may be granted for pediatric members less than 18 years of age when benefits outweigh risks.

Continuation & Reauthorization Criteria

Continuation / Reauthorization

Reauthorization will be granted when ALL of the following are met:

ALL of the following

Physician attests that member is experiencing disease stability or improvement on Briumvi.

New-to-Plan Continuation (on therapy at enrollment)

Authorization may be granted for members new to the plan who are currently receiving treatment with the requested medication, excluding when the product is obtained as samples or via manufacturer’s patient assistance programs.

ALL of the following

Member is currently receiving Briumvi (ublituximab) at enrollment (not if obtained only as samples or via manufacturer's patient assistance programs).

Provider Actions & Requirements

Prior Authorization

Prior authorization required

Prior authorization is required for Briumvi; specialty designation requires dispensing at a contracted specialty pharmacy. Contact phone and fax provided for authorization requests.

All Plans Phone: 877-519-1908
All Plans Fax: 855-540-3693

Documentation Required

Physician attestation for reauthorization

For reauthorization, physician must attest that the member is experiencing disease stability or improvement on Briumvi.

Billing Rule

Specialty pharmacy dispensing requirement

Briumvi has been designated specialty and must be filled at a contracted specialty pharmacy.

Operational thresholds & key dates

Initial & reauthorization approval duration12 months

Effective date07/01/2023

Last review05/10/2023

PayerMassHealth UPPL / Mass General Brigham Health Plan

Scope summaryPrior authorization policy defining coverage criteria, continuation, limitations, specialty pharmacy requirement, and contact information for Briumvi (ublituximab) for Commercial/Exchange plans.

Background

Background: Briumvi (ublituximab) is indicated for treatment of relapsing forms of multiple sclerosis in adults, including clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease. This policy defines prior authorization, coverage criteria (including required diagnosis, neurologist involvement, avoidance of concomitant disease-modifying MS agents, and pediatric exception when benefits outweigh risks), continuation/reauthorization requirements (physician attestation of disease stability or improvement), limitations (initial and reauthorization approvals granted for 12 months), specialty pharmacy dispensing requirement, and contact information for Briumvi under Mass General Brigham Health Plan / MassHealth UPPL for commercial/exchange plans.

Policy Summary

PayerMass General Brigham Health Plan

PolicyBriumvi (ublituximab) prior authorization policy

Policy CodePolicy N/A

Change TypeAdded

Effective DateJul 1, 2023

Next Review Date

Key ActionPrior authorization is required for Briumvi; specialty designation requires dispensing at a contracted specialty pharmacy. Contact phone and fax provided for authorization requests.

SourceLink

On This Page

OpenPayer

Briumvi (ublituximab) prior authorization policy

Coverage Summary

Initial Therapy Criteria

Continuation & Reauthorization Criteria

Provider Actions & Requirements

Applicable Codes

Clinical Evidence & References

Background

Revision History